(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Biodiversity Heritage Library | Children's Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "The American journal of the medical sciences"

Property of the 

Lancaster City and County 
Medical Society 



No 



l\50 



4 




THE 

AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 



ISAAC HAYS, M.D., 

SURGEON TO WILLS HOSPITAL, 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS '. MEMBER OF THE 
AMERICAN MEDICAL ASSOCIATION ," OF THE AMERICAN PHILOSOPHICAL SOCIETY J OF THE 
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA, 
&C. &C &C. 



NEW SERIES. 
VOL. XVII. 




PHILADELPHIA: 
.LEA & BLANCHARD. 

LONDON: 
WILEY & PUTNAM, AND JOHN MILLER. 



1849. 



69443 



Entered according to Act of Congress, in the year 1849, by 
LEA AND BLANCHARD, 
in the Clerk's Office of the District Court of the Eastern District of Pennsylvania. 




PHILADELPHIA : 
T. K. AND P. G. COLLINS, PRINTERS. 



TO READERS J1ND CORRESPONDENTS. 



The following works have been received: — 

On the Employment of Chloroform in Dental Surgery,, its Mode of Exhibition, 
&c. By Francis Brodie Imlach, Dentist, &c. &c. Edinburgh, 1848. (From the 
Author.) 

On the Duration of Labour as a Cause of Mortality and Danger to the Mother 
and Infant, &c. In reply to a Letter of Dr. Collins. By J. Y. Simpson, Prof. Med. 
in the Univ. of Edinburgh. (Extracted from the Prov. Med. and Surg. Journ., 
Nov. 1, 1848.) Edinburgh, 1848. (From the Author.) 

Medical Communications of the Massachusetts Medical Society, Vol. VII., No. 
VII. Boston, 1848. (From Dr. Edward Jarvis.) 

The Transactions of the Provincial Medical and Surgical Association, Vol. XVI., 
Part I. London, 1848. (From the Association.) 

The Principles and Practice of Modern Surgery. By Robert Druitt, F. R. C. S. 
A new American from the last and improved London edition. Edited by F. W. 
Sargent, M. D., author of "Minor Surgery/' &c. Illustrated with 193 wood 
engravings. Philadelphia, Lea & Blanchard, 1848. (From the Publishers.) 

Hints towards the Formation of a more Comprehensive Theory of Life. By 
S. T. Coleridge. Edited by Seth B. Watson, M. D. Philadelphia, Lea & 
Blanchard, 1848. (From the Publishers.) 

Observations on the Pathology of Croup, with Remarks on its Treatment by 
Topical Medications. By Horace Green, A. M., M. D. New York, 1849. (From 
the Author.) 

The Philosophy of Marriage, in its Social, Moral, and Physical Relations, with 
an Account of the Diseases of the Genito-urinary Organs, which impair or 
destroy the reproductive function, and induce a variety of complaints: with the 
Physiology of Generation in the Vegetable and Animal Kingdoms. By Michael 
Ryan, M. D., &c. From the last London edition. Philadelphia, Barrington & 
Haswell, 1848. (From the Publishers.) . 

A Text-Book of Practical Anatomy. By Robert Harrison, M. D., &c. &c. 
With Additions by an American Physician. With numerous illustrations. New 
York, Samuel S. & Wm. Wood, 1848. (From the Publishers.) 

Essays on Tnfant Therapeutics: to which are added Observations on Ergot, 
and an Account of the Origin of the Use of Mercury in Inflammatory Complaints'. 
By John B. Beck, M. D., Prof, of Mat. Med. and Med. Jurisp. in the 'Coll. of Phys. 
and Surg.. New York. New York, 1849. 

A Treatise on Etherization in Childbirth. Illustrated by five hundred and 
eighty-one cases. By Walter Channing, M. D. ; Prof, of Midwifery and Medi- 
cal Jurisprudence in the University of Cambridge. Boston, W. D. Ticknor & Co., 
1848. (From the Author.) 

Clinical Midwifery. Comprising the Histories of five hundred and forty-five 
Cases of Difficult Labour, with Commentaries. By Robert Lee, M. D., F.R S., 
&c. &c. First American from the second London edition. Philadelphia, Lea & 
Blanchard, 1849. (From the Publishers.) 

Lectures on Venereal and other Diseases arising from Sexual Intercourse. 
Delivered in the summer of 1847 at the Hopital du Midi, Paris. By M. Ricord. 
Reported and Translated by Victor de Merie, M. D. Philadelphia,"Ed. Barring- 
ton & Geo. D. Haswell, 1849. (From the Publishers.) 

An Illustrated System of Human Anatomy, Special, General, and Microscopic. 
By Samuel Geobge Morton, M. D., Penn. and Edinb., &c. &c. With 391 en- 
gravings on wood. Philadelphia, Grigg Elliott & Co., 1849. (From the Author.) 



4 



TO READERS AND CORRESPONDENTS. 



Minutes of the Proceedings of the Committee appointed on the 12th Sept., 
1793, by the Citizens of Philadelphia, the Northern Liberties, and the District of 
Southwark, to attend to and alleviate the sufferings of the afflicted with malig- 
nant fever prevailing in the city and its vicinity. With an Appendix. Printed 
by order of the Select and Common Councils of the City of Philadelphia. Phi- 
ladelphia, 1848. (From Charles A. Poulson, Esq., Chairman of the Committee 
of Councils.) 

Annual Report of the Regents of the University on the Condition of the State 
Cabinet of Natural History. With Catalogues of the same. Made to the Senate 
April 1 1th, 1848. Albany, 1848. (From Dr. T. R. Beck.) 

Report made to the House of Representatives of Massachusetts respecting the 
Expediency of appointing Commissioners to Inquire into the Condition of the 
Idiots in that Commonwealth. (From Dr. Jarvis.) 

Report of the Commissioners appointed to Inquire into the Condition of the Idiots 
of Massachusetts, with the Supplementary Report. (From Dr. Jarvis.) 

Reports and other Documents relative to the Ventilation of the School Houses 
of the City of Boston. Boston, 1848. (From Dr. E. Jarvis.) 

Report of the Committee of the American Academy of Arts and Sciences on 
Ventilators and Chimney-tops. March ; 1848. Cambridge, 1848. (From Dr. E. 
Jarvis ) 

Memorial of Lemuel Shattuck, praying for a Revision of the Laws in rela- 
tion to the Registration and Return of Births, Marriages, and Deaths. (From Dr. 
E. Jarvis.) 

Outlines of a New System of Physiology. By Louis Mackall, M. D. Wash- 
ington, 1848. (From the Author.) 

Twelfth Annual Report of the Trustees and Superintendent of the Vermont 
Asylum for the Insane. Sept. 1848. Rutland, 1848. (From Dr. W. H. Rock- 
well.) 

The Twenty-fourth Annual Report of the Officers of the Retreat for the Insane, 
at Hartford, Conn. April, 1848. (From J. S. Butler, M. D., Physician and Su- 
perintendent.) 

Introductory Lecture to the Course of Materia Medica and Pharmacy, in the 
University of Pennsylvania. By George B. Wood, M. D., Prof, of Mat. Med. 
and Pharm. Delivered Oct. 19, 1848. Philadelphia, 1848. (From the Author.) 

An Introductory Lecture Delivered to the Class of Midwifery and Diseases of 
Women and Children in Jefferson Medical Collese. Oct. 18th, 1848. By Chas. 
D. Meigs, M. D. Published by the Class. Philadelphia, 1848. (From the 
Author ) 

An Introductory Lecture to the Medical Class of the University of Louisville. 
By Lunsford P. Yandell, M.D., Prof, of Chem. and Pharm. Louisville, 1848. 
(From the Author.) 

An Introductory Lecture, delivered at the Massachusetts Medical College, Nov. 
1, 1848. By John B. S. Jackson, M.D., Prof, of Path. Anat. Boston, W. D. 
Ticknor & Co., 1848. (From the Author.) 

Introductory Lecture delivered in the Medical College of Georgia at the open- 
ing of the Annual Session, Nov. 6, 1848. By Joseph A. Eve, M. D., Prof, of Ob- 
stetrics and Diseases of Women and Infants. Published by the Class. August, 
1848. (From the Author.) 

Introductory Lecture delivered to the Class of Starling Medical College, Nov. 
15, 1848. By Frederick Merrick, A.M., M.D., Prof. of Chem. and Bot. '"Colum- 
bus, 1848. (From the Author.) 

A Discourse on the Influence of Diseases on the Intellectual and Moral Powers, 
delivered as an Introductory Lecture at the College of Physicians and Surgeons 
in the City of New York, Oct. 30, 1848. By Joseph Mather Smith, M D., Prof, 
of Theory and Pract. Phys. and Clinical Med. New York, 1848. (From the 
Author.) 



TO READERS AND CORRESPONDENTS. 



5 



The Report of the Surgeon -General to the Secretary of War at the opening of 
the Second Session of the Thirteenth Congress. Washington, 1849. (From 
Thos. Lawson, Surg.-Gen.) 

Catalogue of the Trustees, Faculty, and Students of the Medical College of 
the State of South Carolina. Session 1847-48. 

Fifth Annual Catalogue for 1847-48 of Rush Medical College. Chicago, 111., 
1848. . 

Catalogue of the Officers and Students of Dartmouth College, for the academi- 
cal year 1848-49. Hanover, 1848. 

A Plea for Obstetrics. Introductory Lecture to the Course of Midwifery, in the 
Medical Department in Pennsylvania College. For the Session of 1848-49. By 
John Wiltbank, M. D. Published by the Class. Philadelphia, 1848. (From 
the Author.) 

An Introductory Lecture on the Coinciding Tendencies of Medicines. By 
Jared P. Kirtland, M. D., Prof, of Theory and Pract. Med. and Phys. Diag. in 
the Med. Dep. of the Western Reserve College. Cleveland, 1848. (From the 
Author ) 

The following Journals have been received in exchange: — 

Revue Medico-Chimrgicale de Paris. Sous la direction de M. Malgaigne, 

Chirurgien de l'Hopital de St. Louis, &c. Aug., Sept., Oct., 1848. 

Revue Medicale Francaise et Etrangere. Par J. B. Cayol. Recueil des tra- 

vaux de la Societe de Medecine de Pans. March, April, May, June, July, Aug., 

1848. 

Gazette Medicale de Paris. May, June, July, Aug., Sept., 1848. 

Journal de Medecine et de Chirurgie Pratiques a FUsage des Medecins Pra- 
ticiens. Par Lucas-Championniere, D.M P. June, July, Aug., Sept., 1848. 

Annales de Therapeutique Medicale et Chirurgicale et de Toxicologie. Pub- 
liee par M. le Docteur Rognetta. May, June, July, Aug., 1848. 

Journal des Connaissances Medico-Chirurgicales. June, July, Aug., Sept., Oct., 
1848. ;Y>; 

Journal des Connaissances Medicales Pratiques et de Pharmacologie. May, 
June, July, Aug., Sept., 1848. 

Journal de Pharmacie et de Chimie. May, June, July. Aug., Sept., 1848. 

Annales Medieo-Psychologiques Journal de PAnatomie, de la Physiologie et 
de la Pathologie du Svsteme^Nerveux. Par MM. les Docteurs Baillarger, Cerise 
et Longet. May, 1848. 

La Lancette Francaise, Gazette des Hopitaux Civils et Militaires. May 15 to 
Oct. 5, 1848, inclusive. 
The Edinburgh Medical and Surgical Journal. Oct. 1848. 

Guy's Hospital Reports. Edited by Geo. H. Barlow, M.D., E. Cock, F. R. C. 
S., E. L. Birkett, M.D., and Alfred Poland, F. R C. S. Oct. 1848. 
The British and Foreign Medico-Chirurgical Review. Oct 1848. 

Monthly Journal and Retrospect of the Medical Sciences. Oct., Nov., Dec, 
1848. 

The London Medical Gazette, and Journal of Practical Medicine, and the Col- 
lateral Sciences. Sept., Oct., Nov., 1848. 

Provincial Medical and Surgical Journal. Edited by R. J. N. Streeten, M.D. 
Foreign editor W. H. Ranking^ M.D. Sept., Oct., Nov., 1848. 

Dublin Medical Press. Sept., Oct., Nov., 1848. 

The Journal of Psychological Medicine, and Mental Pathology. Edited by 
Forbes Winslow, M D. Oct. 1848. 

The Dublin Quarterly Journal of Medical Science. Nov. 1848. 
Medical Times. Sept., Oct., and Nov., 1848. 

The American Journal of Pharmacy, published by authority of the Philadelphia 

1* 



6 



TO READERS AND CORRESPONDENTS. 



College of Pharmacy. Edited by Joseph Carson, M.D. ; Prof. Mat. Med., and 
Wm. Proctor, Jr., Prof, of Pharra. Oct. 1848. 

The Western Journal of Medicine and Surgery. Edited by Drs. Drake, Yan- 
dell, and Colescott. Oct., Nov., and December, 1848. 

North- Western Medical and Surgical Journal. Edited by Wm. B. Herrick, 
M.D., and John Evans, M.D., Proffin Rush Medical College. Aug. and Sept. 
1848. 

The New Jersey Medical Reporter, and Transactions of the New Jersey Medi- 
cal Society. Edited by Joseph Parrish, M.D. Oct. 1848. 

The American Journal of Science and Arts. Conducted by Profs. B. Silliman 
and B. Silliman, Jr., and Jas. D. Dana. Nov. 1848. 

The Buffalo Medical Journal, and Monthly Review of Medical Science. Edited 
by Austin Flint, M.D. Oct., Nov., and Dec, 1848. 

Southern Medical and Surgical Journal. Edited by Paul F. Eve, M.D. Oct. 
and Dec. 1848. 

The Boston Medical and Surgical Journal. Edited by J. V. C. Smith, M.D. 
Oct. 1848. 

The Medical Examiner, and Record of Medical Science. Edited by R. M. 
Huston, M.D. Oct. and Nov. 1848. 

The New York Journal of Medicine and the Collateral Sciences. Sept. and 
Nov. 1848. 

The St. Louis Medical and Surgical Journal. Edited by Drs. M. L. Linton, J. 
S. Moore, Wm. M. McPheeters, and J. McDowell. Sept.. Oct., Nov., and Dec, 
1848. 

The American Journal of Insanity. Edited by the Officers of the New York 
State Lunatic Asylum, Utica. Oct. 1848. 

The Ohio Medical and Surgical Journal. Edited by John Butterfield, M. D. 
Nov. 1848. 

The Western Lancet and Hospital Reporter. Edited by L. M. Lawson, M. D., 
and John P. Harrison, M. D. Nov. and Dec. 1848. 

The Annalist. Edited by N. S. Davis, M. D. Nov. and Dec 1848. 

The Charleston Medical Journal and Review. Edited by P. C. Gaillard, 
M. D., and H. H. De Saussure, M. D. Nov. 1848. 

The New Orleans Medical and Surgical Journal. Edited by Drs. J. Harrison 
and A. Hester. Nov. 1848. 

Communications intended for publication, and Books for Review, should be sent, free 
of expense, directed to Isaac Hats, M.D., Editor of the American Journal of the Medical 
Sciences, care of Messrs. Lea & Blanchard, Philadelphia. Parcels directed as above and 
sent (carriage paid) under cover, to John Miller, Henrietta Street, Covent Garden, Lon- 
don; or to Wiley & Putnam, New York; or W. D. Ticknor, Boston; or M. Hector Bos- 
sange, Lib. quai Voltaire, No. 11, Paris, will reach us safely and without delay. We 
particularly request the attention of our foreign correspondents to the above, as we are 
often subjected to unnecessary expense for postage and carriage. 

All remittances of money, and letters on the business of the Journal, should be addressed 
exclusively to the publishers, Messrs. Lea & Blanchard. 

QCj* The advertisement-sheet belongs to the business department of the Journal, and 
all communications for it should be made to the publishers. 



CONTENTS 



OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

NO. XXXIII. NEW SERIES. 

JANUARY, 1849. 



ORIGINAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE 

I. Ligature of the Left Subclavian Artery for Subclavian Aneurism ; with a 
Remarkable Deviation of the Vessel and Consequent Change of its Rela- 
tions. By J. Mason Warren, M. D., one of the Surgeons of the Massachu- 
setts General Hospital. - - - - - - -13 

II. On the Advantages of Simple Dressings in Surgery. By Edward R. Squibb, 
M.D., Assistant Surgeon U.S.N. (Communicated by Thomas Harris, 

M. D., Chief Bureau Med. and Surg.) - - - - - 17 

III. A new Treatment of Catarrh. By John A. Lockwood, M. D., Surgeon 
U.S. Navy. 21 

IV. A Case of Congenital Encysted Tumour, on the right side of the Chest, 
successfully treated with the Seton. By S. D. Gross, M. D., Professor of 
Surgery in the Medical Department of the University of Louisville. - 22 

V. Case of Gun-shot Wound of the Chest. By A. M. Blanton, M. D., of 
Frankfort, Kentucky. - - - - - - - 23 

VI. Extracts from the Records of the Boston Society for Medical Improvement. 

By Samuel Parkman, M. D., Secretary. - - - - - 26 

VII. Cases of Premature Labour from unusual causes, with Remarks. By 
Isaac G. Porter, M. D., of New London. - - 33 

VIII. Report of Cases treated in the Pennsylvania Hospital. By George Fox, 

M. D., one of the surgeons. - - - - - - 42 

IX. Notes of Hospital Cases. By Henry Hartshorne, M. D. - - 47 

X. On the Etiology of Intermittent and Remittent Fevers. By James F. Gay- 
ley, M. D., of Philadelphia - - - - - - 53 

XI. Cases of Partio-general Paralysis. By Pliny Earle, M. D. ; Physician to 

the Bloomingdale Asylum for the Insane, New York. - - - 73 

XII. Chloroform Inhalation in Amputation of the Thi&h. By Robert Robson, 
M.D. - - - - 91 

XII L Exsection and Disarticulation of the Lower Jaw for Osteo-Sarcoma. 
By Geo. C. Blackman, M. D., Fellow of the Royal Medical and Chirurgical 
Society of London. - - - - - - -93 

XIV. Vaginal Hysterotomy. By John H. Griffin, M. D., of Salem, Roanoke 
County, Virginia. - - - - - - - - 94 

XV. Amputation in Gun-shot Wounds. By Richard McSherry, M.D. P. A., 
Surgeon U. S. N. (Communicated in a letter to the editor.) - - 96 

XVI. A Case of Intussusception. Communicated by Wilmer Worthington, 

M. D., of Westchester, Penn. - - - - - - 97 



8 



CONTENTS. 



REVIEWS. 

ART. PAGE 

XVII. A Treatise on Etherization in Childbirth. Illustrated by five hundred 
and eighty-one cases. By Walter Charming. M. D , Professor of Midwifery 
and Medical Jurisprudence in the University at Cambridge. "Give me 
the facts,' 7 said my Lord Judge: '-'your reasonings are mere guess-work of 
the imagination." — Old Play. Boston, 1848: William D. Ticknor and 
Company, 8vo. pp. 400. - - - - - - - 99 

XVIII. Observations on the Pathology of Croup, with remarks on its treatment 
by topical medications. By Horace Green, A.M., M. D. &c. &c. — New 
York: 1849. 12mo. pp. 115. - - - - - - 116 

XIX. Boa Vista Fever. — Report of Gilbert King, M. D., Inspector of Hospitals, 
ordered to be printed by the House of Commons, March 10th. 1848. 
London, 1848 : folio, pp. 16. [Remarks of J 0. McWilliam, M. D.,' on the 
Report of Dr. King. London, 1848: folio, pp. 15 ] - - - 128 



BIBLIOGRAPHICAL NOTICES. 

XX. Essays on Infant Therapeutics : to which are added Observations on Ergot, 
and an account of the origin of the use of Mercury in Inflammatory Com- 
plaints. By John B. Beck, M. D., Professor of Materia Medica and Medi- 
cal Jurisprudence in the College of Physicians and Surgeons of the Uni- 
versity of the State of New York, &c. &c. New York, 1849 : 12mo. pp. 
117. W. E. Dean, Publisher. 143 

XXI. Die Krankheiten derMilz; Eine pathologisch-therapeutische Abhand- 
lung, von Carl Berthold Heinrich, A A. L L., Mag. Doct. d. Phil. Med. u. 
Chir. etc. etc. Leipzig, 1847 : 8vo. pp. 452. 

The Diseases of the Spleen : A Pathologico-therapeutic Treatise. By Charles 
B. Heinrich, M. D., &c. &c. ...... 143 

XXII. Researches on the Motion of the Juices in the Animal Body. By Jus- 
tus Liebig, M. D., Professor of Chemistry in the University of Giessen. 
Edited from the manuscript of the author. By William Gregory, M. D., 
Professor of Chemistry in the University of Edinburgh. Edited from the 
English edition. By Eben N. Horsford, A. M., Rumford Professor in the 
University at Cambridge. 12mo. pp. 99. Lowell, 1848. Daniel Bixby & 
Company. - 150 

XXIII. The Nature and Treatment of Deafness and Diseases of the Ear; and 
the Treatment of the Deaf and Dumb. By William Dufton, M.R. C.S. 
Philadelphia: Lea & Blanchard, 1848: 12mo. pp. 120. With a Plate. - 154 

XXIV. Clinical Midwifery; comprising the Histories of five hundred and 
forty-five cases of difficult, preternatural and complicated Labour. W T ith 
Commentaries. By Robert Lee, M. D., F. R. S., Physician to the British 
Lying-in Hospital and St. Marylebone Infirmary, Lecturer on Midwifery at 
St. George's Hospital. First American from the second London Edition. 
Philadelphia, Lea & Blanchard, 1849: pp. 235, 12mo. - - -155 

XXV. The Principles and Practice of Medicine, in a Series of Essays. By 
John W. Hood, M.D. " By the union of study and practice, we attain a 
knowledge of the profession." 8vo. pp. 263: Philadelphia, Thomas, Cow- 
perthwait & Co., 1848. - - - - - - - 156 

XXVI. The Principles and Practice of Modern Surgery. By Robert Druitt, 
F. R. C S. — A New American, from the Last and Improved London Edition. 
Edited by F. W. Sargent, M. D., Author of " Minor Surgery," &c. Illus- 
trated with 193 wood engravings. Philadelphia: Lea & Blanchard, 1848: 

pp. 576, 8vo. - • - - - - - - 157 

XXVII. A System of Human Anatomy. General and Special. By Erasmus 
Wilson, M. D., Lecturer on Anatomy, London. Fourth American from the 
last London Edition. Edited by Paul B. Goddard, A. M., M. D., Prof. Anat. 
and Histology in Franklin Med. College: with two hundred and fifty-one 
illustrations by Gilbert. Philad.: Lea & Blanchard, 1848. - - 158 



CONTENTS. 



9 



ART. PAGE 

XXVIII. A complete practical work on the Nature and Treatment of Venereal 
Diseases and other affections of the Genito-Urinary Organs of the Male and 
Female. Illustrated by a great number of beautifully coloured plates; and 
many finely executed illustrations on wood. By Homer Bostwick, M. D., 
&c. New York: Published by Burgess, Stringer & Co., 1848: pp. 348, 4to. 

A Treatise on the Nature and Treatment of Seminal Diseases, Impotency, and 
other kindred affections: with practical directions for the management and 
removal of the cause producing them: together with Hints to Young Men. 
Illustrated by numerous engravings. By Homer Bostwick, Surgeon. Se- 
cond edition. New York: Burgess, Stringer & Co., 1848: pp, 251, 12mo. 



158 



158 



QUARTERLY SUMMARY 

or THE 

IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 



FOREIGN INTELLIGENCE. 
Anatomy and Physiology. 



page 

1. On the Spleen. By Drs. Verga 
and Tigri. - - - - 159 

2. On the Capillary Circulation. By 

M. Bourgery. - - - - 159 

3. On the Action of the Pancreatic 
Fluid. By M. Ch. Bernard. -160 

4. Note on one of the Anomalies of 
the Right Subclavian Artery, with 



PAGE 

Absence of the Recurrent Nerve 
of the Right Side. By M. De- 
marquay. ... - 160 
On the Chemical Phenomena 
manifested by different substances 
introduced into the Organism. By 
M. Bernard. - - - - 161 



Organic Chemistry. 



On the Acidity and Alkalinity of 
certain of the Human Fluids in 
the state of Health and Disease. 
By M. Andral. - 



164 



On certain forms of Alkaline 
Urine. By Dr. G. Owen Rees. - 165 
I. Characters of the Urine in Bright's 
Disease. By A. B. Garrod, M. D. 166 



Materia Medica and Pharmacy. 



9. Action of Calomel on the Liver. 
By. M. Michea. - - - 167 

10. An Effect of Opium, upon which 
sufficient stress has not hitherto 
been laid. 167 

11. Physiological Action of the Io- 
dide of Potassium. By MM. Boys 

de Loury and Costilhes. - - 168 

12. Action of Chloroform. By M. 
Malgaigne. - - - - 169 



13. Administration of Mercury in 
Small Doses. By Mr. Hancock. 170 

14. Narcotic Principle in Indian 
Hemp, a Peculiar Resin. By 
Messrs. T. & H. Smith. - - 170 

15. Camphor and Chloroform Mix- 
ture. By T. & H. Smith. - - 170 

16. Supposed Test for Cod-Liver 
Oil. By Mr. Hockin. - - 171 



10 



CONTENTS. 



Medical Pathology and Therapeutics and Practical Medicine. 



PAGE 

17. On the Anatomy of the Enlarged 
Thyroid Gland in Bronchocele. 

By Professor Ecker, of Basle. - 172 

18. On the Healthy and Diseased 
Structure of Articular Cartilage. 

By John Birkett, F.L.S.,F.R.C.S. 172 

19. On the Pathological Changes in 
Mucous Inflammations. By Rud. 
Virchow. - - - - 173 

20. Pathological Anatomy of the 
Kidneys. By Dr. W. T. Gairdner. 174 

21. Diseased Condition of the Tra- 
cheo-bronchial Mucous Mem- 
brane of the Artisans of Sheffield, 
and the Statistics of Mortality 
among them. By Dr. Craigie. - 175 

22. Fungus Hsematodes of the Brain. 

By Mr. Prankerd. - - - 176 

23. On Photuria, or Luminous Urine. 

By M. Fallot. - - - - 177 

24. The Vibration of the Thoracic 
Walls, — a Diagnostic Sign of 
Disease. By M. Monneret. - 177 

25. On Influenza and Cholera. By 

Dr. Marc D'Espine. - - - 178 

26. On Delirium in Pneumonia. By 
M.Grisolle. - - - - 178 

27. Inflammation and Ulceration of 
the (Esophagus. - 179 

28. Peculiar Obstruction of the 
Bowels. By Daniel Donovan, 

M. D. 181 

29. On the Simultaneous Progress 
of Gout and Phthisis. By Dr. 
Garrod. 182 



PAGE 

30. Influence of Physical Agents 

on Variola. By M. Serres. - 183 

31. On the Employment of Nitrate 
of Potass in Acute Rheumatism ■ 
with Suggestions for the Use of 
Saline Solutions as External Ap- 
plications in Local Rheumatic In- 
flammation. By W. R. Basham, 
M.D. 184 

32. Collodion in the Treatment of 
Diseases of the Skin. By Eras- 
mus Wilson, Esq. - 185 

33. Epilepsy cured by cauterization 
of the Sinciput. By Doctor Le- 
breton. 186 

34. Arsenic in Furunculusand Acne. 

By Dr. Schweich. - - - 186 

35. On the Use of Stomachics in 
Dyspepsia. - 187 

36. Belladonna in the Nocturnal In- 
continence of Urine in Children. 

By M. Trousseau. - - - 187 

37. Local Application of Chloroform 

in Lumbago. By M. Moreau. - 187 

38. Local Application of Chloroform 
to a Pelvic Tumour. By M. Le- 
groux. 187 

39. Case of Hydrophobic Mania 
successfully treated with Chloro- 
form. By R. Y. Ackerley, Esq. 188 

40. Use of Chloroform in Insanity. 

By Dr. M'Gavin. - - - 189 

41. Insanity cured by Sulphate of 
Quinine. By M. Piorry. - - 190 



Surgical Pathology and Therapeutics and Operative Surgery. 



42. Ligature of the Primitive Carotid 
Artery for an Aneurismal Tumour 
in the Temporal Region. By M. 
Barrier. 191 

43. Strangulated Hernia, reduced by 
Fright. By M. Cabaret. - - 191 

44. Application of Laudanum in 
Orchitis. By M. Voillemier. - 191 

45. Rigidity of the Hand after Frac- 
ture of the Forearm. By M. Her- 
vez de Chegoin. - - - 191 

46. A New Mode of Performing 
Lithotomy by the Rectum. By 

M. Maisonneuve. - - - 192 

47. Reduction of a Dislocation for- 
ward of the Inferior Surface of 
the Fifth Cervical Vertebra. By 

M. Vrignonneau. - - - 192 



48. Vertical Dislocation of Patella. 

By M. Debrou. - - - - 192 

49. Disease of the Appendix Cceci 
cured by Operation. By Dr. Han- 
cock. 193 

50. Treatment of Hemorrhage after 
Excision of the Tonsil. By M. 
Hatin. 195 

51. Gun-shot Wounds. By Dr. Wa- 
ters. 195 

52. Character of the Orifices of Gun- 
shot Wounds. - 196 

53. Dilatation of Gun-shot Wounds 
unconnected with Fracture. - 197 

54. Balls lodged in the Bones. H6- 
pital St. Louis, service of M. Jo- 
bert. 198 

55. Treatment of Fractures of the 



CONTENTS. 



11 



PAGE 

Extremities in connection with 
Gun-shot Wounds. - - - 199 

56. Operations for excising parts of 
the Hip-joint in Scrofulous Caries 
of the Articulation. By Mr. H. 

B. Norman. - - - - 203 

57. Removal of a Carious Portion 

of a Rib. By Alexander Linoli. 204 

58. Fracture of the Head of the 
Humerus, and laceration of the 



PAGE 

Axillary Vein. By Mr. Fraser. - 205 

59. Ovariotomy— death. ByMr.H. 

G. Potter. 205 

60. Chloroform in Surgical Practice. 

By Prof. Miller and Dr. Duncan. 205 

61. Local Anaesthesia. By M.Jules 
Roux. 205 

62. Tetanus from Injury of the Ankle 
— Amputation— Repeated Ether- 
ization—Death. By M. Roux. - 206 



Ophthalmology. 



63. Structure of the Vitreous Hu- 
mour. By Dr. Hannover. - 207 

64. Cholesterine Cataract. By W. 

R. Wilde, Esq. - - - 208 

65. Sparkling Eye. By W. R. Wilde, 
Esq. 209 

66. Chloroform in the treatment of 



Ophthalmia. By M.Uytterhoeven. 210 

67. Ergot of Rye a Remedy for 
Excessive Dilatation of the Pupil 
from Belladonna. By M. Com- 
perat. 210 

68. Ergot of Rye in Mydriasis. By 

J. F. M'Evers, M.D. - - 210 



Midwifery. 



69. On the Mammary Secretion as 
a Sign of Pregnancy. By Dr. 
Alex. Peddie. - - - - 210 

70. Protracted Lactation. By Dr. 
Moir. 214 

71. Sore Nipples and their Treat- 
ment. By Drs. M'Clintock and 
Hardy. - - - - - 214 

72. Fissures of the Nipples. By 

M. Jose Leon. - - - - 215 

73. Rupture of an Impregnated 
Uterus, from a collection of Pus 

in its Cavity. By Dr. Guzzo. - 215 

74. Statistics of the Induction of 
Premature Labour. By Dr. Hoff- 
man. - - - - 215 

75. Prolapsus of the Funis, at the 
second month of Pregnancy. By 



Mr. I. B. Brown. - - - 216 

76. Quinine as prophylactic of 
Puerperal Fever. By M. Leudet. 217 

77. Medicated Pessaries. By Dr. 
Simpson. 217 

78. Plaster Belt in Abdominal Tu- 
mours. By Dr. Simpson. - - 218 

79. Employment of Chloroform in 
Midwifery. By Dr. Simpson. - 218 

80. Case of Retention of a Foetus 
in the Uterus for Eleven Years. 

By Dr. Vondorfer. - - - 220 

81. Case of Spontaneous Amputa- 
tion of the Forearm, and Subse- 
quent Rudimentary Regeneration 
of the Hand of the Foetus. By 

Dr. Simpson. - 220 



Cholera. 



82. Course of Cholera — its rate of 
progress, — its mortality — its pre- 
liminary stage. - - - - 221 

83. New "Remedies for Epidemic 
Cholera. - - - - - 223 

84. Persian Petroleum in Cholera. 

By Dr. Robertson. - - - 223 

85. Treatment of - Cholera by Chlo- 
roform in Peckham House Asy- 
lum. By Dr. James Hill. - - 223 

86. Treatment of Cholera by Chlo- 
roform at the Peckham House 
Asylum. By Messrs. Hill and 
Ferguson. - 224 



87. Chloroform Inhalations in Cho- 
lera. By William Robertson, 

M. D. 225 

88. Means of Applying Heat to 
Cholera Patients. By Dr. William 
Robertson. - 225 

89. Injection of Saline Fluids into 
the Veins. By William Robert- 
son, M. D. .... 226 

90. Directions Relative to the Pre- 
vention and Treatment of Cholera, 
by the Royal College of Physi- 
cians of London. ... 226 



12 



CONTENTS. 



Medical Jurisprudence and Toxicology. 



page 

91. Researches on the Principal 
Metallic Poisons, and Mode of 
Ascertaining their Presence. By 

M. Abrue. - - - - 228 

92. Case of Poisoning by Arsenic, 
in which the symptoms were un- 
usually delayed. By Walter 
Clegg, Esq. - - - - 230 

93. Poisoning with Chloride of Zinc 



— Suggestion of an Antidote. By 
Dr. Thomas Stratton. - -231 

94. Antidote to Strychnia. By Dr. 
Isaac Pidduck. - - - - 231 

95. Child born betwixt the end of 
the sixth and middle of the se- 
venth month and brought up. By 
Robert Annan. - - - - 231 



Miscellaneous. 

96. Remarks on Endosmose. By j 97. State of Medical Education in 
Ph. Jolly. 232 [ Turkey. 233 



AMERICAN INTELLIGENCE. 
Original Communications. 



Cod-Liver Oil in Phthisis. By J. 

Young, M. D. - - - - 235 
Case of Extensive Fracture of the 

Os Frontis, with escape of a por- 



tion of the Cerebral Substance. — 
Recovery. By J. Wistar Walke, 
M.D. 238 



Domestic Summary. 



Case of Compound Fracture of the 
Cranium with loss of Cerebral 
Substance. By Elias Horlbeck, 
M.D. 239 

(Edematous Laryngitis, successfully 
treated by Scarifications of the 
Glottis and Epiglottis. By Gur- 
don Buck, Jr., M. D. - - - 240 

A New Feature in the Anatomical 
Structure of the Genito-Urinary 
Organs not hitherto described. 
By Gurdon Buck. Jr., M. D. - 249 

Remarks on some of the Diseases 
which prevailed in the 2d Regt. 
Mississippi Rifles, for the first six 
months of its service. By Thos. 
N. Love, M.D. ... 251 

Anthropo-toxicologia. By Dr. C. E. 
Lavender. .... 253 

Bite of the Cerastes Nasicornis, the 
Horned Viper of Western Africa. 
By Dr. T. S. Savage. - - 254 

Case of Traumatic Tetanus success- 
fully treated. By S. C. Thornton, 
M. D. 255 

Ununited Fracture of the Femur of 
one year's standing, successfully 
treated by Resection, Denudation, 
and Retaining the Ends of Bone 
by means of Wire. v By Daniel 



Brainard, M. D. , - - - 256 

Successful Amputation at the Shoul- 
der-joint, for Gun-shot Wound — 
patient under Chloroform. By 
Paul F. Eve, M.D. - - - 257 

Aneurismal Tumour of a branch of 
the Epigastrium bursting into the 
Scrotal Sac. By M. Z. Kreider, 
M. D. 258 

Fibrous Tumour of the Uterus — 
Gastrotomy. By Dr. J. Deane. - 258 

Case of Labour where Delivery was 
accomplished through the Peri- 
neum. By S. C. Ellis, M. D. - 260 

Cases and Remarks upon the use of 
Chloroform in Natural Labour. 
By Edwin B. Stimson, M. D. - 260 

Statement of fifteen cases of Mid- 
wifery in which Chloroform was 
administered. By G. N. Burwell, 
M.D. 261 

Case of Puerperal Convulsionstreat- 
ed by Chloroform. By James P. 
White, M. D. - - - - 262 

Malignant Cholera. - - - 263 

Statistics of the Medical Colleges of 
the United States for the Session 
of 1847-48. - - - - 263 

Medical Literature. - - - 264 

American Medical Association. - 264 



THE 



AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR JANUARY 1 849. 



Art. I.— Ligature of the Left Subclavian Artery for Subclavian Aneu- 
rism ; with a Remarkable Deviation of the Vessel and Consequent 
Change of its Relations. By J. Mason Warren, M. D., one of the 
Surgeons of the Massachusetts General Hospital. 

The great novelty attending the ligature of the larger arterial trunks, and 
of the subclavian in particular, gives interest and importance to any case 
of operation on those vessels. In the latter this interest is increased by its 
deep situation, causing in many cases a great difficulty of reaching it, and 
by the importance of the organs in its immediate neighbourhood. Accord- 
ing to the valuable tables furnished by Dr. Norris, in some former numbers 
of this Journal, out of 69 cases of ligature of the subclavian artery, 36 
recovered, and 33 died, or nearly one-half. In operations on the iliac 
arteries, out of 118 cases, 85 recovered, and 33 died. From 38 cases of 
operation on the carotid artery for aneurism, 22 recovered, and 16 died. 
In every instance where it has been necessary to place a ligature on the sub- 
clavian artery on the tracheal side of the scaleni muscles, the result has 
been fatal. 

The case which I propose at present to relate, offers some peculiar 
points of interest, apart from the general one of the ligature of the vessel. 
Among the principal of these may be mentioned the fact of a ligature having 
been applied to the artery for an aneurismal tumour situated above the 
clavicle, being, so far as I am aware, the first case of this kind that has 
had a successful result, because the recorded aneurismal tumours in that 
situation have required the application of a ligature within the scaleni, and 
the termination, as stated above, has been unfavourable. Secondly, the 
anatomical peculiarities in the relations of the vessel, to which may be 
attributed the possibility of the ligature on the outside of the scaleni. 
Thirdly, the rapidity with which the collateral circulation was restored, 
No. XXXIII.— Jan., 1849. 2 



14 



Warren, Ligature of the Left Subclavian Artery. [Jan. 



the pulse having been felt at the wrist twenty-four hours after the opera- 
tion. Finally, the length of time the ligature remained attached, ninety-six 
days, notwithstanding all safe means were made use of to detach it. 

Without further prelude I shall proceed to the description of the case. 

Miss A., thirty years of age, of delicate constitution, had a congenital 
club-foot of the worst kind, and, in consequence, a double curvature of the 
spine. For the former of these she was treated eight or ten years since 
by Dr. Brown at his infirmary, and the foot after the section of the tendons, 
followed by the appropriate treatment, was completely brought into its 
natural position, so that she was enabled to walk with ease, without the 
aid of any mechanical support. The curvature of the spine was submitted 
to a similar treatment with the same successful result. 

At the request of Dr. Brown, she consulted me in the early part of Dec, 
1847, for an aneurismal tumour situated just above the scapular end of 
the clavicle, about the size of a pigeon's egg, of which she gave the fol- 
lowing history : 

Four months previous, while in attendance on a sick brother, she had 
occasion to draw the cork from a bottle, and felt at the moment a sudden 
crack at the point where the present tumour is situated. Her attention was 
not attracted to it at the moment, but a short time afterwards a small swell- 
ing having a decided pulsation, was distinguished at that spot, which has 
gone on increasing until it has attained its present size. It had a powerful 
pulsation, and possessed the usual thrill characteristic of an aneurismal 
affection. 

After having examined the tumour and learned its history, I endeavoured 
to discover the subclavian artery in its normal situation beneath the clavicle, 
at the point where it passes over the first rib. To my surprise no large 
vessel or any osseous protuberance answering to the tubercle of the first 
rib, usually taken as the guide to the artery in this position, could be found. 
Different parts of the neck were then explored, which finally led to the 
discovery of a large artery passing obliquely upwards, parallel to, and 
about an inch removed from, .the external border of the trapezius muscle. 
Compression being made at this point, the pulsations of the tumour ceased, 
as well as the pulse at the wrist. There was no question, therefore, in 
my mind that this was the subclavian artery, but it was more difficult to 
determine this remarkable anomaly. 

I now sought for the first rib, and to my surprise discovered both the 
first and a part of the second rib passing obliquely across the neck above 
the clavicle. The insertion of the scalenus anticus muscle into the first 
rib, was at length distinguished; the tubercle, however, was not sufficiently 
developed to be manifest to the touch. The whole osseous system of the 
chest in this case seemed to have undergone a partial displacement. The 
spine and ribs attached had been, as it were, moved upwards; while the 
sternum was carried in an opposite direction. 



1849.] Warren, Ligature of the Left Subclavian Artery. 15 



Making a strong compression on the vessel above the tumour, the arm 
became extremely painful with a sensation of numbness, and on a sub- 
sequent and more careful examination the whole brachial plexus of nerves 
could be discriminated, in immediate contact with the artery. 

As the tumour was rapidly increasing, it was evident, that, considering 
its situation and the great danger of delay, no time was to be lost, if any 
surgical operation was to be resorted to for its relief. 

The patient, a person of much fortitude and force of character, agreed 
at once to the course advised. The operation was performed, on Dec. 
24th, in the presence of Dr. J. C. Warren, Dr. Brown, Dr. Buckminster 
Brown, Dr. Bartlett, of Roxbury, Dr. Morland and Dr. Slade. 

An incision, about two inches long, was made, extending from near the 
outer and upper edge of the sterno-mastoid muscle downwards, in the direc- 
tion of the scapuloclavicular articulation, and an inch from the edge of the 
trapezius muscle, the pulsations of the vessel being the principal guide, as 
the other anatomical marks were wanting. This incision divided the skin 
and superficial fascia ; a second cut opened one of the branches of an artery 
given off from the thyroid axis, which was tied. A nervous band of some 
size was now encountered, and at its side and directly over the artery a 
large vein, apparently the external jugular. The vein was carried to the 
upper part of the wound with a silver hook, and the nerve to the lower ; 
the dragging upon the latter caused a disagreeable and somewhat painful 
sensation in the arm. 

The sheath of the vessel was next opened, the cellular membrane around it 
cleared away, and the aneurism needle, unarmed, passed from below up- 
wards, on account of the difficulty of introducing it in the contrary direction 
from the interference of the scalenus anticus, which had its insertion just 
below. The needle at once encountered and raised the lower nerve of the 
brachial plexus, which was in the most intimate contact with the artery. 
By depressing the handle, and urging the point forwards, with careful 
manipulation the eye of the needle was without difficulty brought out 
between these two organs. The instrument was now threaded with the 
ligature and withdrawn. Careful exploration being made to ascertain if 
any nerve was included in the ligature, the painful sensations in the arm 
caused by drawing the ligature downwards at first led to the supposition 
that this might be the case. But when the same traction was made directly 
upwards, no pain was. felt; the former sensations being produced by the 
dragging on the cervical portion of the brachial plexus, owing to their con- 
nection with the vessel. 

The ligature- was now tied, and the wound dressed. The pulsations in 
the aneurismal sac, as well as those of the radial artery at the wrist, at once 
ceased, and all appearance of the tumour vanished. The patient's arm 
and hand were a little cold directly after the operation, but being rolled in 
flannel they soon regained their natural temperature. 



16 Warren, Ligature of the Left Subclavian Artery. [Jan. 



25th. — Found her quite comfortable. She had passed a quiet night. 

2Qth. — The patient states, that the pulse at the left wrist returned for a 
time last evening, it then disappeared, but returned again, though faintly, 
this morning. I could not discover it at the time of my visit. 

27//i. — She has been somewhat troubled by occasional pains in the arm. 
The pulse was felt yesterday once or twice by Dr. Buckminster Brown, 
being intermittent. The wound has healed by the first intention. She 
has suffered occasionally from palpitation of the heart. 

29th. — The pulse was perceived, though feebly, at the wrist, but could 
not be detected in the axilla. The spot formerly occupied by the aneu- 
rismal tumour, now presents an obvious depression. 

Jan. 2d, 1848. — The pulse is constant at the wrist. 

14th. — The ligature still remains on the artery, notwithstanding the 
traction daily made by the patient in accordance with my directions. A 
number of large vessels, taking their origin from the subclavian, exist in 
different parts of the neck. One of these, apparently the supra-scapular, 
passes directly over the sac, and pulsates so strongly as at first to convey 
the impression of a return of pulsation in the aneurismal tumour. 

March 30th. — Once or twice in the course of the last two or three weeks, 
finding that the ligature on the vessel was not disposed to become detached, 
I have seized it with the forceps, and, holding the artery forcibly down on 
the rib, have twisted the thread with considerable force. This was done 
for the third time yesterday, and immediately afterwards the ligature sepa- 
rated, ninety-six days after the operation. 

The wound almost at once closed. 

I saw this patient on Sept. 14th for the last time. At that period she 
was quite well, had recovered the use of her arm, and was in no way in- 
commoded by the operation, to which she had submitted. The aneurismal 
tumour had in a great measure disappeared ; but it still conveys the impres- 
sion of containing a fluid. Directly on its surface, and incorporated with 
it, is a very large arterial trunk, supposed, as above stated, to be the, supra- 
scapular. This vessel pulsates powerfully, and at first gives an appear- 
ance of pulsation to the tumour ; but by careful manipulation can be sepa- 
rated from it. The pulse at the wrist still remained a little less strong 
than in the corresponding artery of the other side. 

Boston, Nov. 1848. 

To those persons who may have noticed a case of ligature of both caro- 
tids, in the April number of this Journal for 1846, an account of the state 
of this patient after the lapse of three years may not be without interest. 

The object of this operation, it may be remembered, was to allow of the 
excision of a fungous tumour occupying nearly the whole of the lower lip, 
and based on an erectile tissue pervading the tongue, face, neck and chest. 
This tissue was rapidly increasing, and it was hoped that its growth might 
be arrested by thus cutting off the direct supply of blood to it. 



1849.] Squibb, Advantages of Simple Dressings in Surgery. 17 



The arteries were tied in the latter part of the year 1845, and the tumour 
of the lip was then excised without the occurrence of any alarming 
hemorrhage. 

This patient I have had an opportunity of seeing within a few months, 
and of making some observations on the state of the circulation in those 
parts about the face and neck supplied by the carotids. 

The situation of the temporal arteries being explored, no appearance of 
pulsation could be discovered in those vessels. The same was found to 
be the case in regard to the labial arteries. The angular arteries, where 
they inosculate with the nasal branch of the ophthalmic, gave the faintest 
pulsatory motion. 

In the region of the neck were a number of large vessels having their 
origin from the subclavian, among which the supra-scapular was chiefly to 
be distinguished. 

The lip was rather more full in appearance than when the report of the 
case was made, but free from ulceration. 

The functions of the brain had not in any way been disturbed. 



Art. II. — On the Advantages of Simple Dressings in Surgery. By 
Edward R. Squibb, M.D., Assistant Surgeon U.S. N. (Communi- 
cated by Thomas Harris, M. D., Chief Bureau Med. and Surg.) 

Sir: — A desire for the farther promulgation of some facts already known 
to many, induces me to ask the attention of the profession, through you, 
to the advantages of simple dressings in surgery. 

Minor surgery is the every day occupation of almost every surgeon's 
life, and its importance therefore needs no supporting argument, especially 
when a successful avoidance of major surgery has become evidence of 
skill. 

During a very few years' experience in this every-day surgery, some 
principles and facts have been learned, and some deductions drawn, all of 
which verify the maxim extended from midwifery, that " meddlesome 
surgery is bad ;" and much of each day's accumulating experience points 
to the yet farther extension of the same maxim to the remaining depart- 
ment of our science, Medicine. 

The light and simple dressings so ably advocated by Liston and others, 
are rapidly being substituted for the heavy, complicated bandages, poul- 
tices, and ointments, of former treatment ; but their application as thus ad- 
vocated is mainly to the cases of gravity which alone occupy the attention 
of such men, so that, as yet, a corresponding advancement does not appear 



18 Squibb, Advantages of Simple Dressings in Surgery. [Jan. 



to have been made in the treatment of that class of cases so much the 
more numerous, and possibly more important. 

It is, then, to the advantages of dressings always light, and generally of 
water alone, that I wish to add my testimony ; having in chief object, also, 
to deprecate the use of all greasy and of most mucilaginous applications 
in the treatment of simple, indolent or inflammatory sores, and a great 
majority of those of specific character. 

Some comparative observations indicate that many sores which have 
become indolent, irritable or otherwise intractable, have been rendered so 
by treatment ; and that a variation of the dressing, in favour of the simple 
plan, would have, in most cases, prevented this depravation. 

In the wounds and injuries resulting from the ordinary accidents occur- 
ring under my charge, as well as in phlegmon and other superficial in- 
flammations, the following treatment has generally been adopted. 

The part is placed in a position of relaxation and perfect rest: and one 
that can be maintained without weariness is always sought. The divided 
surface, if separated, or having a tendency to separation, are brought into 
contact, preferably, by one or more stitches, not too lightly drawn. If 
the injury is very painful, a single layer or fold of patent lint is made to 
hold as much cold water as possible without dripping, and is laid over the 
part, exceeding, by two or three inches, the size of the injured surface. 
Cold water to supply the loss by evaporation, is periodically poured upon 
the lint, from a spoon, during the continuance of severe pain; the mind 
being as far as possible abstracted from the injury, by whatever means. 
Thus managed, the pain commonly abates in a few hours, when the con- 
stant application of the water may be abandoned, and a piece of oiled silk 
xceeding the lint in size, placed over it. If the wound be upon a limb, 
a single turn of bandage secures the dressing. At the expiration of six 
or eight hours, the oiled silk alone is raised, and the evaporated water re- 
placed. This supplying of the waste by evaporation is continued until 
the covered portion of the surface assumes a white corrugated appearance. 
This white corrugated appearance of surface is usually produced within 
forty-eight hours, and as far as my observation extends, is quite incompati- 
ble with inflammation or much pain ; tenderness of the part, with increase 
of size from effusion, alone remaining. When this corrugation is fully 
established, the wet lint is replaced by a similar dry piece, the oiled silk 
omitted, and a single turn of a roller again fixes this protective dressing. 
Rest in the fixed position is still maintained for a time varying with the 
gravity of the wound, and the remaining tenderness, or exposed position 
of the part. 

The substitution of a state of perfect bodily rest for active exercise al- 
ways tends to constipation, and therefore an aperient is often given within 
twenty-four hours after the commencement of the treatment, the effect of 
which is also beneficially counter-irritant. 



1849.] Squibb, Advantages of Simple Dressings in Surgery. 



19 



The character of the union obtained under this management, is commonly 
that of simple adhesion, or at least something short of the ordinary first 
intention, as no marked inflammatory process can be detected. 

When suppuration occurs under this treatment, it is commonly simple 
in character, and of short duration, only requiring, in modification, that the 
fold of wet lint should be changed on becoming soiled or saturated with 
pus, and the dressing continued during active suppuration. 

It frequently happens that slight wounds of the extremities are not con- 
sidered of sufficient importance to require attention, and become, through 
neglect, and the irritation of motion and foreign contact, much inflamed, 
swollen, ulcerated and very painful. In such, the same management has 
afforded the same satisfactory results, even under the depravation of sys- 
tem induced by the peculiarities of a sailor's life. 

In connection with this class of cases, one circumstance is worthy of 
remark: — namely, that the application of water dressings to suppurating 
surfaces, continued too long, frequently protracts the suppuration. The 
color and corrugation of the surface, with the full granulation of the part, 
are- guides in the use of the dressing. 

Should active suppuration continue intractable, an alternation of wet 
and dry dressings for periods of twenty-four hours will often prove bene- 
ficial. 

The farther continuance of indolent ulceration, from local causes, has as 
yet never failed to yield, when a drop or two of strong solution of some 
bitter astringent vegetable extract as quassia, gentian, cinchona, or of 
tannin itself, or of nitrate of silver, has been applied to the ulcerating sur- 
face at each renewal of the water dressing. 

In one case of very indolent chronic ulceration, a single drop of tincture 
of cantharides was so applied at three successive dressings, and was fol- 
lowed by improvement and recovery. 

A solution of one scruple of nitrate of silver in half a fluid ounce of 
water appears best adapted to common use, in consequence of its free and 
perfect solubility, and the facility with which it is kept ready for use. It 
is best applied from the point of a camel's hair pencil. 

The water, in these dressings, may be applied at any bearable tempera- 
ture above 55° F. in accordance with the purpose to be subserved, or the 
sensibilities of the surface — by general rule, the lower temperatures to the 
higher and more active grades of inflammation. 

I have not known the pain of a recent injury to be increased by the 
application of water, the temperature of which was not below 60°, although 
when below 50° it has frequently increased pain. 

Practically, these dressings may be positively termed warm or cold as 
they are maintained at a temperature above or below that of the surface 
to which they are applied; and such temperature can only be maintained 
by frequent renewal of the dressing. 



20 



Squibb, Advantages of Simple Dressings in Surgery. [Jan. 



As commonly required and used, however, they can be properly termed 
neither cold nor warm; for although applied at a temperature differing from 
that of the surface, they are quickly varied by the contact, and soon ac- 
quire the same temperature. 

Hence, in description, as I have constantly done in practice, I would 
specify three varieties of simple dressing. — First, water dressing, in which 
the dressing, at whatever temperature applied, soon acquires that of the 
surface, and is only renewed as evaporation or cleanliness requires such 
renewal. 

This variety fulfils all the indications to common use in a great majority 
of cases. 

Second. — Cold water dressing, in which an uncovered fold of lint is 
maintained at a temperature below that of the surface by frequent immer- 
sion in cold water, and by evaporation. 

The application of this variety is not so general, being chiefly confined 
to very recent wounds and injuries when active inflammation is to be pre- 
vented rather than remedied, and where immediate union maybe expected. 

Third.- — Warm water dressing, wherein a temperature above that of the 
surface is maintained by the application of a pledget of lint frequently 
immersed in warm water, evaporation being restrained by an impervious 
covering. When the surface is unbroken, this dressing is best made with 
flannel, the limited conducting power of which better adapts it to retain the 
heat. 

Such dressing perfectly subserves all the indications to simple fomenta- 
tion, and will commonly afford speedy relief in the pain and tension of 
established active inflammation. 

These modes of dressing have been very generally used by me for 
nearly four years, and have proved more satisfactory in result than the 
Elm, Flaxseed, crumb of bread, meal, and other poultices which were 
used previously to, and coincidently with them. They have also, in great 
measure, been substituted for the long list of ointments and plasters in 
common use, with evident advantage in many cases. 

The collateral advantages of these dressings are simplicity, cleanliness, 
lightness, cheapness, facility of application and renewal, and that their 
elements are always at hand. 

In conclusion, difference of climate and temperature has in no degree 
affected my high estimation of this method of treating wounds, injuries 
and superficial inflammations, having used it in all latitudes between 40° 
north and 35° south. 

U. S. Brig Perry, off Rio de Janeiro, 
Aug. Uth, 1848. 



1849.] Lockwood, A new Treatment of Catarrh. 21 



Art. III. — Jl new Treatment of Catarrh. By John A. Lockwood, M.D., 
Surgeon U. S.%avy. 

For nearly a year I have pursued a plan of treatment in catarrh, which, 
in numerous instances, unfailingly relieved its initial symptoms almost 
immediately. It is adapted to its earliest stages, when the mucous lining 
of the nasal cavities is dry, tumid and red, accompanied with a feeling of 
heat, fulness, and itching of the part. 

The remedy consists in the application of a solution of nitrate of silver 
to the Schneiderian membrane. It is best applied with a camel's hair 
pencil. The strength of the solution should not be less than eight grains 
of the salt to one ounce of the distilled water. I ordinarily employ a 
solution somewhat stronger — ten grains to the ounce. 

The application is not painful, nor even disagreeable. Its immediate 
effect is to excite a copious serous effusion, which continues for some 
minutes. After this the nostrils are freed from the previous impediment 
to the passage of the breath through them, when the sensation of relief 
becomes at once manifest. With the subsidence of the local swelling, 
the general heaviness and malaise disappear. For some minutes, the 
inhalation of cold air communicates to the mucous lining of the nose a 
feeling of rawness. This, however, is of short duration, after which, un- 
less the inflammation has extended beyond the Schneiderian membrane, 
the cure is complete. 

To accomplish a radical cure, the solution should be applied at the very 
commencement of the attack. When the inflammation has extended to 
the pharynx, &c, it is no longer practicable to subject all the parts affect- 
ed to a treatment which is mainly local. I have, however, applied the 
remedy in many cases where the disease had made several days' progress. 
Then, although no expectations were entertained of removing any symp- 
toms of bronchial irritation which might have supervened, the relief to 
the head was always satisfactory, by the liberty it afforded to the passage 
of air through the nostrils. 

M. Deschamps, in the Gazette des Hoipitaux for October 1847, recom- 
mends snuffing up the nostrils every two hours a solution of opium in 
water, as an effectual cure for coryza. This method I have not tried. 
Before reading an account of it, I had for several months employed the 
solution of nitrate of silver with such happy results, that I was indisposed 
to seek for any- better plan. The insufflation of ardent spirits will often 
check an incipient catarrh, but the remedy is unpleasant and painful. 



22 



Gross's Case of Congenital Encysted Tumour. [Jan. 



Art. IV. — A Case of Congenial Encysted Tumour, on the right side 
of the Chest, successfully treated with the Seton. By S. D. Gross, 
M. D., Professor of Surgery in the Medical Department of the University 
of Louisville. 

On the 17th of February, 1847, Mr. Radcliff, of Paducah, Kentucky, 
consulted me on account of a large tumour, occupying the right side of the 
chest of his infant, a boy three weeks old. The child was well grown, 
remarkably hairy, and of a dark complexion. His health in other respects 
was excellent; the tumour, which existed at birth, was of a globular shape, 
and was six inches in the vertical direction by seven and a quarter in the 
transverse. Its circumference at the base was thirteen inches. Reaching 
to within an inch and a half of the sternum in front and the spine behind, 
it extended, on the one hand-fas low down as the tenth rib, and, on the 
other, as high up as the axilla, pushing the corresponding arm out at a right 
angle with the trunk. The skin of the axilla was red and chafed, from the 
friction of the limb. The tumour was soft, elastic, fluctuating, and trans- 
lucent, like a hydrocele; its surface was somewhat tabulated, of a bluish 
color, and traversed by large veins; the skin was perfectly sound, and the 
part was entirely free from pain. Whenever the child cried, the tumour 
was rendered remarkably tense, from the expansion of the chest. 

The tumour had not interfered with the birth of the child, and had 
increased but little since it was first noticed. On puncturing it at two 
points with a cataract needle, a yellow serum issued. 

The true character of the case being thus ascertained, and not wishing 
to employ at once any means of permanent cure, I punctured the tumour 
on the same day with a small trocar, and drew off, in a full stream, seven 
ounces of serum, of the color of Madeira wine. It was saline in its taste, 
ropy and coagulable by heat. Only about two-thirds of the fluid were 
evacuated. The puncture was closed with adhesive plaster. 

No unpleasant symptoms followed the operation. At the end of the third 
day, the sac was soft, flabby, and only ten inches in circumference. The 
trocar was again introduced, and the remainder of the fluid, six ounces in 
quantity, and of a light reddish color, removed. The walls of the collapsed 
cyst were brought into contact by a graduated compress, confined by a 
roller. The child slept well the night after the operation, and the next 
day there was no discoloration, pain, or tenderness. 

On the 24th of February, that is, four days after the second operation, 
the dressing was removed, and the sac found much shrunken. Some 
accumulation, however, had again taken place, and I therefore determined, 
after evacuating the sac, to introduce a seton. This was composed of a 
few silk threads, and was inserted in the same manner as in the operation 



1849.] Blanton, Case of Gun-shot Wound of the Chest. 23 

for hydrocele, the interval between the two openings being about two 
inches and a half. 

The presence of the foreign body was soon followed by severe inflam- 
mation. The child became excessively restless, and the tumour, red, hot, 
and tender on pressure, rapidly increased in size. In consequence of these 
symptoms the seton was withdrawn at the end of forty-eight hours. The 
suffering, nevertheless, continued without any manifest abatement for three 
days longer, notwithstanding the use of laxatives and saturnine fomenta- 
tions with opium. On one occasion, indeed, the little patient had quite a 
severe convulsion. As the inflammation subsided, a free discharge of 
matter took place, and lasted upwards of a week, accompanied with great 
emaciation and debility. Gradually, however, all the bad symptoms dis- 
appeared; appetite and sleep returned; the tumour steadily decreased in 
violence under the influence of the saturnine applications ; and finally, at 
the expiration of a month, nothing remained at the site of the disease 
except a slight hardness. 

I saw my little patient again last May, nearly fifteen months after the 
operation, and was happy to find that the cure remained perfect. 



Art. V. — Case of Gun-shot Wound of the Chest. By A. M. Blanton, 
M. D., of Frankfort, Kentucky. 

Ed. Cahill, set. about 40, a large muscular man of 180 pounds weight, 
private in Capt. Turpin's Company, 2d Regt. Kentucky Infantry, was 
wounded on the 23d Feb. 1847, at the battle of Buena Vista, in the left 
breast, under the middle point of the clavicle, by a large shot — liis com- 
panions say grape shot, as they were too far distant for musketry to take 
effect, and as they noticed the discharge of a Mexican cannon simultaneously 
with his falling. 

The ball entered between the second and third ribs, cutting the inferior 
edge of the former and the superior of the latter, passed through the lungs, 
again through the ribs ranging horizontally, and lodged, as there is every 
reason to believe, under the scapula. 

He was borne off the field in a collapsed condition, blood and air rush- 
ing copiously from the dreadful wound, and was placed against a wall in 
an upright position, it being discovered that he was threatened with suffoca- 
tion when his body was at all inclined horizontally. 

He was carried to Saltillo the same night, and placed in the cathedral, 
used as a temporary hospital, where I found him on the 26th in the posi- 
tion above named ; breathing short and difficult ; unable to pronounce three 
words without pausing ; having a constant troublesome cough with bloody 



24 



Blanton, Case of Gun-shot Wound of the Chest. 



[Jan. 



expectoration ; not much pain about the wound, which discharges in twenty- 
four hours from a pint to a quart of blood and bloody serum ; air also 
was rushing through the orifice at each act of respiration. His skin was 
cool and moist; pulse 100 and weak; countenance blanched and anxious. 
When he was struck his left arm was elevated so that the relative position 
of the great pectoral muscle with the hole between the ribs was altered 
when the arm was permitted to fall, and the opening into the chest was 
valvular. By raising the arm to a level with the clavicle, the wounds 
in the muscle and between the ribs were made to correspond, and 
presented an opening into the chest one inch in diameter. I attempted to 
probe the wound, but every time the instrument was inserted he would 
faint and compel me to desist ; pieces of torn lung were forced through 
the opening by the efforts of coughing and by the discharges of blood. 

He had been kept as quiet as possible since the injury was received, 
had eaten scarcely anything, and taken no medicine save a laxative and 
opiate. 

A large piece of lint was kept over the wound, and below were placed 
large cloths to receive the discharges. He was put on a mattress ; one 
half of which was placed upright against a wall; a half cup of tea and a 
small piece of stale bread were allowed three times a day, and he was 
kept nauseated six hours in twenty-four by powders of ipecac, and calo- 
mel ; and each night took | gr. of morphia to enable him to sleep. 

March 1st. Has been doing very well; inclination to fever has been 
checked by extreme abstinence and nauseants. But little pure blood ex- 
pectorated or thrown out of the wound, which is almost free of its slough 
and disposed to suppurate. 

4th. Can hear the air escaping through the wound at ten paces, when 
he coughs ; discharge is sero-purulent and of offensive odour, amount- 
ing to at least a pint in twenty-four hours. Has pleurisy, which is dis- 
appearing under the use of almost complete starvation, nauseants, mer- 
cury and opiates ; the last named always necessary to procure sleep. He 
also takes every other day a dose of castor oil. Pulse is 100 and weak ; 
surface pale and cool. The wound externally is clean ; attempted to ex- 
amine it with a probe, but he fainted as before, not from pain, but from a 
peculiar tickling sensation, as he expressed it. 

I had the arm elevated, and picked away several spiculae of bone from 
the ribs, and then exposing the chest to a very strong light, saw entirely 
through the cavity, a rib posteriorly ivhite and denuded. He complains 
of a dull heavy and constant pain under the scapula and about the shoulder. 

25th. Nothing of much interest has occurred ; has had pleuris seve- 
ral times, which was relieved directly by the before-mentioned reme- 
dies, and as many times after a little exertion has coughed up several 
mouthfuls of blood. The wound has contracted to the size of a dime ; 
discharges about 3ij daily and permits the escape of air, with a whistling 



1849.] Blanton, Case of Gun-shot Wound of the Chest, 25 

sound. He can sleep with his body depressed to an angle of thirty de- 
grees. 

April \0th. Discharge nearly ceased ; wound round and a quarter of 
inch in diameter; air escapes when he coughs ; still restricted to a very 
spare diet ; for two weeks has taken no medicine, except several laxatives 
and opiates ; walks several hundred yards during the day. 

May 1st. Has been allowed for ten days, a liberal diet; wound closed ; 
a very little air escaped several days since. Still complained of pain in 
the shoulder and weakness of the corresponding arm ; has fattened ; can 
lie down; appetite and digestion good; goes through the city, walking 
several miles a day; when he takes severe exercise, has some difficulty 
of breathing. Discharged from the hospital. 

In June, Cahill came to the United States, a hearty, robust looking 
man, of one hundred and eighty pounds weight, and I had not heard any 
particulars about him since, until in July, when I was told he had died, 
and that an examination had been made of his body. Feeling a great 
interest in his case, a friend was requested to furnish me a description of 
the appearances his body presented, and in a few days sent the following 
letter : — 

" Winchester, Ky., Aug. 16th, 1848. 

" Dear Sir: — I am sorry that I am not able to give you a more minute 
history of Cahill's case. 

" I saw him only once during his last illness, and only a few times since 
his return from Mexico. 

" When he first came home he was as healthy and robust a looking 
man as I ever saw ; he weighed at that time (June 1847), I have'no doubt, 
two hundred pounds; but Dr. Duncan, his physician, told me that he had 
frequent attacks of haemoptysis ; and that he started frequently out of his 
sleep, saying that he felt as if he was suffocating. 

" He was taken sick about three weeks before his death, with every 

symptom of inflammation of the stomach he had a feeling of 

weakness, as he expressed it, in his breast. 

"He has been living since his return at a tavern in the capacity of a 
bar-keeper, and I have been told that he was quite intemperate. 

" On opening the'chest it was discovered that the left lung was completely 
atrophied, not being larger than your hand, and of a dark livid colour, and 
there were dense organized bands crossing the cavity in various directions, 
which had to be cut before the ball could be found. 

" When discovered it was between the spinal column and end of the 
fifth rib, which was detached from the back-bone and fractured an inch 
from its extremity ; the fractured portion was forced out of its place so as 
to form a resting place between the adjoining ribs and spine for the ball. 
The ball was made of a metal resembling the metal of which bells are 
made, and weighed four ounces and five grs. ; there was with the ball a 
brass button, weighing nearly two drachms, both of which were almost 
covered with a thick membrane, and also within the same sac there was a 
considerable quantity of exfoliated bone ; those portions of the back-bone 
and ribs which were near the ball were entirely denuded. 



26 Parkman, Extracts from Soc. for Med. Improvement. [Jan. 



"The pericardium was entirely agglutinated to the heart, the right side 
of which was somewhat atrophied. The right lung had morbid attach- 
ments between the pleura pulmonalis and costalis, and also to the dia- 
phragm ; it was of a lighter colour and softer than natural. 



Art. VI. — Extracts from the Records of the Boston Society for Medical 
Improvement. By Samuel Parkman, M. D., Secretary. 

Membranous Croup, treated by Cauterization of the Fauces and 
Larynx with Nitrate of Silver. — Dr. Clark had treated five cases in this 
way : three had recovered — two had died. 

Aug. 14. — Case I. — A boy two and a half years of age, who had been 
ill two or three days, and had had croupy respiration for thirty-six hours 
before he was seen. Cauterization was practised with some alleviation of 
suffering, but death ensued on the third day. 

Case II. — A girl five years of age and of scrofulous diathesis. The 
croupy respiration was well marked, and had been present more than 
twenty-four hours. Cauterization was employed and much false mem- 
brane was expectorated at various intervals. Considerable relief was ob- 
tained in this way ; but the child died on the fourth day, with symptoms 
of exhaustion rather than of suffocation. 

Case III. — A delicate girl of three and a half years, who had sore throat 
with hoarseness. False membranes existed in patches on the tonsils, &c. ; 
cauterization was employed. Croupy respiration, however, came on the 
next evening, but it was relieved in twelve hours, by the expectoration of 
small fragments of false membrane streaked with blood. The paroxysms 
of dyspnoea returned several times, being terminated in the same way, and 
the patient ultimately recovered, although the voice was not wholly restored 
for three weeks. 

Case IV. — A child of four years. The symptoms in this case were not 
very severe, although quite distinct. The croupy breathing had continued 
without remission for twelve hours — false membranes were remarked in 
the throat. The treatment here was followed by gradual and speedy re- 
covery, without the expulsion of any large amount of false membrane. 




Very respectfully, 

A. S. ALLEN, M.D." 



1849.] Parkman, Extracts from Soc. for Med. Improvement. 27 

Case V. — The patient, a healthy girl of six years, was seen early in the 
disease, which lasted a fortnight. She had at first a sore throat and a febrile 
attack which disappeared the second day. The only symptom which per- 
sisted was a slight and increasing hoarseness, and patches of lymph were 
to be seen on the tonsils and spreading thence back toward the larynx. 
These increased until the whole throat was invested with a coating of 
the lymph and the croupy respiration had supervened. The caustic was 
regularly applied from the beginning, and the expectoration of the mem- 
brane began almost as soon as the breathing became much embarrassed. 
The paroxysms of distress and the intervals of relief followed each other 
in this way for nearly three days, when the respiration slowly assumed 
its natural character. The voice could not be raised above a whisper for 
several days later. 

No medicine but Dover's powder was given, and this was repeated often 
enough to keep the patient constantly under its influence. The caustic 
was of the strength of xl grs. to 5j of water, and was used with the small 
curved probang. The expectorated membranes were exhibited. 

Aug. 28. — Dysentery, peculiar Post-mortem Appearances. — Dr. Jack- 
son reported a case of this disease that had occurred in the practice of Dr. 
Homans. The patient was a child six years of age, and died on the fourth 
day of the disease. The case was remarkable for the amount of retching 
that existed, and for the character of the discharges ; these last were very 
frequent, more or less bilious, and contained very little blood, but masses 
of a substance that must have been lymph, though it was supposed during 
life to consist of some undigested farinaceous food. On dissection, the 
whole of the large intestine, to within an inch of the ccecal valve, was 
found to be lined by a whitish curdy exudation, beneath which the mucous 
surface was of a deep cranberry red colour ; no ulceration ; solitary glands 
somewhat developed, and muscular coat thickened as usual. The small 
intestine was not affected ; but in another case that has recently occurred in 
a still younger child, Dr. J. found redness with an effusion of lymph, not 
merely upon the mucous membrane of the lower portion of the ileum, but 
upon some of Peyer's glands ; the large intestine being diseased essentially 
as in the above case. Dr. J. alluded to a specimen in the Society's Cabinet 
that shows the same form of inflammation of Peyer's glands in dysentery; 
and with regard to the effusion of lymph generally, he seemed disposed 
to consider it as characteristic of the disease in children, though as by no 
means confined to them. 

Observations on Dysentery. — Dr. Fisher, from a long observation, 
thought the following laws were established in the disease, and desired 
to call the attention of gentlemen to their investigation. 1st. The true 
dysenteric symptoms are preceded by a preparatory period during which 



28 Parkman, Extracts from Soc. for Med. Improvement. [Jan. 



there is more or less diarrhoea, &c. &c. 2d. The dysenteric stage seems 
to obey a law of duration, no case terminating in less than eight days. 
3d. The disease does not occur a second time in the same individual. 
On this point Dr. F. had found his experience confirmed by inquiries 
made among a number of practitioners in this city. 4th. Treatment had 
little influence to arrest the disease. 5th. As regards contagion, Dr. F. 
had observed the following facts. A child and its mother died of dysen- 
tery three years since at Dorchester ; the child's aunt came from West 
Roxbury and grandmother from Providence, R. I., to nurse these two in 
their illness. After their return to their respective homes, they were 
both attacked with the disease ; in the family of the aunt, it was communi- 
cated to the husband, two children and a servant; and in the family of the 
grandmother, to a daughter and two or three others. 

Sept. 25.—- Whortleberry Seeds considered as specimens of Hemp-Seed 
Urinary Calculi. — Dr. Jackson exhibited a quantity of whortleberry seeds 
that were said to have been passed from the urinary bladder, and had been 
regarded as hemp-seed calculi. The fact in the case was proved by the 
most thorough examination. The patient was a lady, thirty years of age, 
and "in point of morals, <fcc, above suspicion;" she was suffering at the 
time from anasarca. Dr. J. also referred to a second case, that had recently 
occurred in this city, and where the same kind of seed appeared to have 
been used ; the patient here also was a female, and probably above sus- 
picion. 

Laryngitis — Tracheotomy. — Death from Bronchitis and Pulmonary 
Congestion. — Dr. J. B. S. Jackson exhibited the larynx and upper portion 
of a trachea taken from a patient under the care of Dr. Townsend at the 
hospital, showing great redness of the mucous membrane, with infiltration 
of pus in the submucous cellular narrowing the rima glottidis. Dr. J. 
exhibited the plate from Cruveilhier's Morbid Anatomy descriptive of 
this affection, and the comparison showed the closest resemblance. The 
history of the case was as follows : A stout, plethoric man in the hospital with 
fracture of the forearm, complained of sore throat, which was prevalent in 
the ward, with a tendency to erysipelas, in consequence of which he was 
removed to another room. The next day he was suddenly attacked with 
urgent dyspnoea, which increased with such great rapidity and with so much 
edematous swelling of the neck externally, that tracheotomy was at once 
decided upon. The operation was much embarrassed by the remarkable 
shortness of the patient's neck and the edematous infiltration. During its 
performance the dyspnoea was aggravated to such a degree as to threaten 
immediate suffocation; and the trachea was punctured with a flat trocar, 
and the opening enlarged with a probe-pointed bistoury. A very consider- 
able quantity of blood escaped into the air-passages. But after the intro- 



1849.] Parkman, Extracts from Soc. for Med. Improvement. 29 



duction of a canula, the patient rallied. The next day he was quite com- 
fortable walking about his room. But the second day after the operation, 
lie was again attacked with dyspnoea and died after three hours. The 
mucous membrane lining all the air passages was found of a vivid redness, 
and the lungs choked with a frothy serum. 

Anomalous Tumour in the Abdomen. — Dr. Jackson had seen a case lately 
that seemed to him particularly obscure. The patient was a young married 
woman, perfectly healthy in appearance, and had been aware of the ex- 
istence of the disease for some months. All of the functions were most 
carefully investigated; but nothing could be discovered to explain the case. 
The tumour was situated in the right side of the abdomen, below the liver; 
and was of a regular, rounded or somewhat flattened form, about the size 
of an orange ; solid to the feel, and slightly tender on pressure ; it was 
about as movable as a loose cartilage in the knee-joint, disappearing en- 
tirely under the cartilages of the ribs when the patient reclined on her back, 
and falling out at once as she turned toward the left side. Some years 
ago Dr. J. met with a case that resembled the above in every particular, 
except that the general health was rather delicate ; he followed it for some 
time, but no change ever occurred, or anything to explain its nature. 
One of his friends, to whom Dr. J. mentioned these two cases, had also 
seen one that was very similar. The patient is a lady, now about sixty- 
nine years of age, and subject to dyspepsia; but to no especial symptoms 
that can be referred to the tumour; this was first noticed in the year 1819, 
soon after a miscarriage at the seventh month, and it has continued 
to be felt from time to time since then ; though for the last two years it 
has not been examined; it is not tender, and as to size, it may sometimes 
be perceived through the dress ; but in regard to situation and mobility, it 
corresponds perfectly with the above cases. 

Excision of the Elbow-joint. — Dr. H. J. Bigelow exhibited the pieces 
removed, consisting of three inches of the humerus, a like length of the 
ulna, and the head of the radius above the biceps insertion. The joint 
had been diseased about eighteen months, with fistulous openings, at the 
bottom of which dead bone was detected by the probe. The patient had 
some cough, with the physical signs of induration at the apex of one lung, 
and some constitutional symptoms, as emaciation, <fec. The operation was 
performed two days since, and thus far the patient is doing well. 

Oct. 9. — Ligature of the Internal Iliac Artery, for a Traumatic Aneu- 
rism of the Gluteal. — Dr. H. J. Bigelow. A middle aged Irish woman 
was stabbed in the right buttock by her husband, on the evening of the 4th 
of July last. By the evidence of the physician, who was called, a very 
large quantity of blood was lost. But the bleeding ceased under compres- 
No. XXXIII.— Jan., 1849. 3 



SO Parkman, Extracts from Soc. for Med. Improvement. [Jan. 



sion,and the woman was enabled to resume her usual occupations. Three 
or four weeks subsequently there appeared a numbness and weakness of the 
extremity of the wounded side, and soon after a small tumour was observed 
in the situation of the cicatrix of the wound. On her entrance into the hos- 
pital in September, there was a tumour over the upper part of the ischiatic 
notch, about the size of a lady's apple, with an unequivocal though not 
strong pulsation, and a very marked souffle. The tumour extended into the 
pelvis, and could be felt both per vaginam and per rectum. No doubt 
could be entertained of the character of the tumour. Taking into view 
the fact that the wound of the artery must necessarily have been directly 
at the ischiatic notch, rendering the possibility of discerning it there a 
matter of great doubt, it was decided to tie the internal iliac. During her 
residence at the hospital, and previous to the operation, the numbness of 
the right lower extremity increased, and several large bullae like those of 
pemphigus appeared on the same limb. The operation was performed 
Sept. 30th. The incision was made above and parallel to Poupart's liga- 
ment, the peritoneum raised from the iliac fossa; and the artery readily 
attained. After the application of the ligature the aneurismal symptoms 
ceased. The patient continued comfortable for two days ; when symptoms 
of peritoneal inflammation commenced, and she died the eighth day after 
the operation. At the autopsy a considerable quantity of lymph was found 
in the peritoneal cavity ; but adhesion had taken place in the course 
of the wound. The right os innominatum, which was exhibited with the 
parts attached, showed, 1st. The ligature around the internal iliac artery 
just above its division, and a satisfactory clot formed between this spot and 
the division of the common iliac. 2dly. The wound of the gluteal artery 
immediately at its emergence from the notch, and the aneurism composed 
of two portions, one about the size of a pigeon's egg, formed in the cellular 
tissue ; and the other in the substance of the pyriformis muscle, which latter 
was the portion felt during life on the inside of the pelvis. In both, the 
blood was firmly coagulated. The sciatic nerve was compressed and flat- 
tened on the spine of the ischium. 

Oct. 23. — Hydrophobia. — Dr. Coale read the following case occurring 
recently in his practice. 

John Fleming, a hearty full-fed boy, seven years of age, born in England 
but living in this country for the last four years, was brought to me one 
day, by his mother, with a slight laceration on the knuckle of the little 
finger of the left hand. The story was, that an hour before, on his way to 
school, he threw a stone at a dog under a wagon and it flew out and bit 
him and returned to lie down again. I saw no reason to do more than 
give some directions about dressing the hand very simply, and was told a few 
days after that it was entirely healed. Three weeks after, on Saturday 
Sept. 30th, his mother sent him to me about 2 P.M., saying he had been 



1849.] Parkman, Extracts from Soc. for Med. Improvement. 31 



out of sorts for two or three days ; and had refused to drink water for 
twenty-four hours. I at once determined not to favour any play to the 
imagination which might make this a case of hydrophobia. Looking at the 
throat I found it swollen somewhat, about the fauces. I asked him to 
take a drink on pretence of washing out his throat; but he refused it cry- 
ing. An active cathartic was prescribed, with directions to let me know 
if he was not better in the morning. I received a message next morning 
to call, and found him on a little settee in the corner of the room. His 
look was stupid, skin cool, pulse 80. Tongue as yesterday, a little furred. 
The powder had acted slightly. His rest had been very slight, and much 
disturbed. He complained of a little pain at the epigastrium ; but nowhere 
else, though his mother said he had complained of headache also at 
times. I asked him to wash his mouth out so that I could see it. He 
took a tablespoonful of water into his hand, and as if violently resisting 
and yet violently endeavouring, held it about six inches from his mouth; 
and then suddenly threw it violently against his teeth and swallowed it 
with a convulsive choking, falling back on the pillow and slightly scream- 
ing. After a moment or two he walked across the room to let me look into 
his mouth. I still resisted the tendency towards calling it hydrophobia, 
and prescribing pediluvia and aperients left him. The next day he was 
better, and not knowing at that time the remitting character of the disease, 
I was relieved of my fears. He swallowed with ease. Walked across the 
room and seemed livelier. His mother, however, said he had had a 
troubled night ; seeing phantoms ; boys looking in at the window, &c. 
Pulse frequent; no heat of skin; no lessening of bodily strength. 

Tuesday, Oct. 10//?. Visited him with Dr. Oliver. Symptoms much 
more unfavourable. Pulse over 100. His skin not hot ; eyes suffused and 
sleepy, or stupid looking. Involuntary shivering. Lying on his back 
with head thrown back. Phantasms more frequent and distressing. Could 
sit up without assistance. Attempts to swallow water accompanied with 
violent spasms, principally opisthotonic, indeed very decidedly so. Upon 
asking to see his tongue, it was protruded convulsively very far; the eyes 
being widely opened at the same time. Answered questions naturally ; 
but with an expression of alarm. Picking his bedclothes ; taking imaginary 
worms out of his mouth, and out of the water offered to him ; and talking 
wildly when not spoken to. Pressure at nape caused shrieks and opisthoto- 
nos. Bowels had not been moved. Prescribed a very active cathartic; and 
a blister to the nape. Dr. J. Ware, who saw the patient this day, suggested 
chloroform. None was at hand, and it was 4 P. M. before I could visit him 
again. I found that at 2 he had commenced vomiting, and had vomited 
some three or four times. His countenance expressed great prostration. 
Extremities cold. Pulse not to be counted. Respiration not hurried. 
Spasms more frequent, and more easily excited. Much mucous rale. 
Two dejections involuntarily and unconsciously. Mind always wander- 



32 Parkman, Extracts from Soc. for Med. Improvement. [Jan. 



ing, though recalled for a moment. Attempted to administer chloroform. 
Much resistance to it. More tractable when his father administered it. 
At one time I thought him under the influence of it; but his expression 
was that of a dying child, and I directed it to be discontinued. The most 
urgent symptom now was debility. Coldness of nose and extremities. 
Pulse too rapid to count. Sweat on face. Sinking of features. Directed 
brandy and chloroform every half hour. Administering this caused spasms, 
but not as much horror of the fluid. On one occasion he remarked he had 
spilt more than half, and asked for some more. When not aroused he talked 
much at intervals, and then would lie quiet until a spasm came on. These 
were increasing and commencing with a general shiver and then affecting 
the muscles of the back and extensors. They were not very violent; never 
raised the shoulder from the bed; but consisted simply in stretching the 
head, neck and the arm out; and stiffening of the trunk. About half past 
five I had to leave, and asked Dr. Buckminster Brown the favour to watch my 
patient as long as convenient. He saw him very soon after ; found him 
lying with his eyes wide open ; pupils dilated ; surface heated, in a pro- 
fuse sweat. Pulse feeble, fluctuating, 232. in a minute; and just afterwards 
208. Every ten minutes the child was seized with a convulsive gasp, and 
then with a general convulsion ; the head being briskly thrown or drawn to 
the left side and opisthotonos strongly marked. These were immediately 
produced, or greatly aggravated by the introduction of liquid into the mouth. 
He appeared to be partially sensible of what was said ; would gaze on 
a spoon offered to him, fixing his eyes glaringly upon it as it approached 
his mouth, and then taking a small swallow with a convulsive gasp and 
struggle, was thrown into a spasm, and an expression of great suffering 
came over his countenance. Symptoms of depressed vitality were marked. 
Delirium. Dr. B. remained with him one hour and a half, say till 7. At 
eight I was again with him and found the same appearances ; but with 
greater prostration of strength, and evident symptoms of approaching disso- 
lution. Fanning him produced convulsions. At half past 9 Dr. Brown 
again saw him, and reports the convulsions not so violent ; legs cold to 
knees. Brandy and water given ; but at once rejected from the mouth 
with frothy matter. A light produced no change on the pupils, which 
were widely dilated. The face was bedewed with sweat at times. Left 
him at 11 with the symptoms of debility fast increasing. From this time 
until death, the spasms were slight but easily excited, and vomiting accom- 
panied them. He died at 2 A. M., Oct. 11th. 

Post-mortem examination with Dr. C. E. Ware. All organs of abdo- 
men and chest healthy. Pericardium had a little, say |oz. of fluid (clear) in 
it. Right auricle enormously distended with blood. Spinal column opened. 
Much venous engorgement; marrow removed from commencement of 
cauda equina to medulla oblongata; but nothing abnormal observed. 



1849.] 



Porter's Cases of Premature Labour. 



S3 



Enormous Ovarian Disease. — Dr. Jackson had lately examined a case 
of this disease, remarkable for the size of the tumour. The patient was 
under the care of Dr. Hay ward. She was unmarried, and aged 27 years; 
her health had been failing for a couple of years ; the abdomen had been 
observed increasing in size within the space of ten months. The cata- 
menia had ceased within three or four months. The only suffering was from 
distension. She had continued about house till within three days of her 
death, which was sudden. The right ovary, which was the one diseased, 
was found almost universally adherent, presenting myriads of cysts, the 
largest being two-thirds the size of a water pail ; two or three the size of 
an adult head. The contents being more or less glutinous in all ; in the 
largest like thick veal broth ; and in some much thinner ; in very many 
like white of egg, and in others like thick glue. The colour of the con- 
tents generally more or less red ; in some dark red, in others brownish, 
in very many of a pearly opalescence ; and in not a few pellucid. No 
encephaloid or other malignant appearance. No fat or hair. The uterus 
externally was normal. The left ovary was two and a half times its natural 
size, presenting one cyst containing a glairy fluid. The liver and intestines 
were pushed upwards. The tumour and its contents weighed 89 pounds. 



Art. VII. — Cases of Premature Labour from unusual causes, with Re- 
marks. By Isaac h. Porter, M.D., of New London. 

" The saying of Hippocrates, that acute diseases in pregnant women 
are mortal, is full of truth when applied to their producing abortion." — 
Mons. Jacquemier. 

A writer in the Medico- Chir. Rev., Jan. 1847, p. 56, in remarking on 
the above says : " We suppose our author, here, is alluding to the fact, 
that before death occurs in acute diseases, the uterus usually casts off the 
ovum — which has been particularly noticed by Dr. Montgomery and others. 
* * When acute diseases are not intense enough to produce abortion, the 
patients are not in a worse condition, for treatment, than women who are 
not pregnant; but when abortion takes place, before the disease is cured, 
it is generally fatal." 

The accuracy of these views must be readily conceded, as embodying 
a general law, subject, however, to exceptions. Abortion, or premature 
labour, following'acute disease, is rather a measure of the violence of that 
disease, than an active cause of the fatal result, which may ensue. To 
the disparagement of morals, in our large cities, the facility and safety with 
which criminal abortions are procured, abundantly show the comparative 
harmlessness of parting with the ovum, even when produced by the un- 



34 



Porter's Cases of Premature Labour. 



[Jan 



skillful and violent means of the abortionist. In intractable vomiting, 
during pregnancy, and in other sympathetic or irritative affections, which 
are sufficiently violent to produce abortion, the safety of the mother is 
thereby often secured. \ 

Case 1.— -The foregoing remarks have especial reference to the case now 
to be detailed. Before entering upon it, however, a peculiar set of symp- 
toms, occurring anterior to acute disease, will first be mentioned. The 
patient is twenty-three years of age, of short stature, florid complexion, 
full habit, and of good general health. — Dec. 1843, being then in the seventh 
month of the first pregnancy, she was suddenly attacked with indistinct- 
ness of vision, and severe headache, with numbness of the right side of 
the tongue, and of the right arm. Only the half of objects was visible — 
pulse frequent and irritable ; but not full, and corded. Fearing from her 
full habit an attack of apoplexy, a vein was opened ; cold was applied to 
the head, a mustard pediluvium was ordered, and also an active cathartic. 
The affection gradually subsided, and on the next day she had merely an 
ordinary headache. 

After a second confinement in Aug. 1845, the same symptoms occurred 
on the third day, and as, at that time, debility rather than signs of conges- 
tion, existed, tinct. nux vom. in doses of ten drops was given with evident 
happy effect, not only on the local symptoms but as a tonic to the stomach. 

Substantially the same symptoms occurred in a third pregnancy (Feb. 
1847), she being then in the seventh month, and a few weeks prior to the 
acute attack, soon to be mentioned. They also occur when she is not 
pregnant, and generally can be traced to sedentary occupation and full 
diet, and are ordinarily preceded by symptoms of indigestion, though the 
attack has the suddenness of an electric shock. Four other cases, two of 
them during gestation, have lately occurred to the writer where these 
amaurotic symptoms have occurred, in connection, solely, with gastric dis- 
turbance, and which have been immediately relieved by emetics in some 
and cathartics and tinct. nux vom. in others. The attack is usually sudden ; 
blindness, either total or partial, is succeeded by headache, and this by 
numbness of the tongue and arms and nausea. In one case there was facial 
paralysis. Vomiting, either spontaneous or induced, shows the stomach 
deranged in its secretions, and filled with crudities. There is no novelty 
in the idea, that amaurosis may arise from gastric and uterine irritations. 
Its symptoms, however, occurring in pregnancy, are with some reason 
generally supposed to depend upon vascular turgescence in the brain, and 
to indicate free depletion. If attended with sense of fullness in the head, 
full pulse, and other symptoms of plethora, the treatment is unquestionably 
correct. To avoid, however, unnecessary resort to the lancet, it is well 
for the young practitioner to remember the gastric origin of similar symp- 
toms, a point perhaps not fully inculcated in obstetrical writers. Should 
there be good ground for doubt, in any case, prudence and the best interest 
of our patients demand that a vein be opened. 

April 9th, 1847. At 1 1 A. M. patient was attacked with violent pain, 
of a constrictive character, between the shoulder blades, about the sixth 
and seventh dorsal vertebras, involving the spine and a space to the left of 
it, and gradually extending to the region of the stomach, duodenum and 
liver. Pulse quick, irritable and weak. She had applied mustard paste 
to the back, before my arrival, had placed her feet in a mustard bath, and 



1849.] Porter's Cases of Premature Labour. 35 

taken a dose of sulph. mag., which, as she thought, operated speedily. 
Two grains of opium were given and immediately vomited ; next, two tea- 
spoonfuls of McMunn's elixir of opium in aromatic infusion, which, being 
retained a short time, she obtained a few minutes troubled sleep. The 
pain, however, continued excruciating, and gradually passed to the abdomen 
and occasionally into the left portion of the epigastrium. Anodyne fomen- 
tations and poultices were constantly applied; also cups to the spine, but 
without any mitigation of suffering. 

10th. The patient obtained little or no sleep during the previous night, 
although one ounce elix. opii was taken, a part of which was vomited. 
Pain in stomach and bowels extreme; stomach so irritable as to reject 
almost everything. Calomel gr. x. made into a hard pill, with one or 
two grains ext. tarax. was exhibited and retained.* In three hours it was 
followed by a dose of castor oil, which was retained until evening, when 
vomiting having recurred it showed itself on the surface of the matters 
ejected. Leeches were this day applied to the abdomen, and a blister to 
the spine. The bowels still remaining confined, the calomel was repeated 
in the evening, and in the course of the night following, oil crot. tig., but 
with no effect other than that of increasing the irritability of stomach. 
Enemas of the most active kind, with and without the intervention of the 
stomach-tube, were frequently administered. Pulse exceedingly rapid, 
irritable and thready, and counted with the greatest difficulty ; thirst urgent ; 
tongue coated with a brown fur. Countenance, however, though express- 
ive of extreme suffering, never exhibited that death-like expression which 
in connection with other grave symptoms portends immediate dissolution. 

llth. At 9 o'clock A.M., the symptoms remaining the same, the pa- 
tient was placed in a warm bath. It was grateful, and seemed gradually 
to soothe the distress. After a lull of an hour, labour pains commenced, 
and being alternate, were welcomed as a grateful substitute, and resulted at 
4 P. M. in the birth of a foetus of the eightli month. The labour 
was easy, but respiration in the child was with difficulty established. 
Symptoms of cyanosis neonatorum soon showed themselves; and it died 
in eighteen hours after birth. The mother was greatly exhausted after 
delivery; but was free from pain. In the evening following, the bowels 
were moved, for the first time, since the hour of the attack, and subse- 
quently more freely. The pulse remained 140 for four or five days, but 
her recovery was steadily progressive; and at the end of the month, she 
was in the enjoyment of ordinary health. 

Was the foregoing a case of congestion of the spinal marrow, or was 
it "cramp of the stomach and duodenum" referred to by Churchill and 
others — or was it a case of internal strangulation of the intestine, which 
was spontaneously relieved while the patient was in the warm bath ? The 
primary symptoms seemed to have reference to the spine ; but in the pro- 
gress of the case, although no external signs of hernia were discovered, 

* The efficacy of this combination, in irritable states of the stomach, especially such 
as arise from biliary derangements, bilious colic, &c, may not be generally known. After 
every other purgative, and even calomel, in bolus, has been vomited, this is almost 
always retained, provided the stomach be otherwise perfectly empty and the patient 
quiet. Even though vomiting should once or twice occur, yet from the specific gravity 
of the pill, it is rarely ejected, while as it gradually dissolves in the stomach it may exert 
the efficacy of small doses of this mineral, in cholera infantum, and other irritable con- 
ditions of this organ. 



36 Porter's Cases of Premature Labour. [Jan. 



intestinal obstruction was strongly indicated. There was every reason to 
fear that the case would prove a confirmation of the aphorism of Hippo- 
crates already quoted, but to which it happily forms an exception. 

Case II. — In the following case, owing to peculiar circumstances, a 
post-mortem examination was not obtained, and though we can merely 
speculate respecting the immediate cause of death, it is conceived, that 
there are points of interest, if not of instruction, connected with it. 

A lady thirty-one years of age, at the time of her death, of scrofulous 
parentage, and of highly nervous temperament, was attacked (1840) with 
alarming hemorrhage, after the birth of her second child. After her third 
confinement (1842), anticipating a like occurrence, a full dose of ergot 
was administered twenty minutes before the birth. It is proper here to 
state that she approached the period of labour with the utmost apprehen- 
sion. So confident was she of a fatal result, that for many days and nights 
she obtained no sleep; and family arrangements, in anticipation of her 
death, were fully made. Either from the prostrate condition of the nerv- 
ous system, or the depressing effect of the ergot, or both, an alarming 
state of the patient followed. The loss of blood was less than on the 
former occasion, but the prostration was much greater. Frictions and 
pressure, the application of cold, and the exhibition of acet. plumb., in 
liberal doses, constituted the chief treatment. Not fully aware at that 
time of the distressing effect of ergot, and resisting, on theory, a free use 
of stimuli in hemorrhage, they were sparingly administered, until urgent 
danger was apparent. The happy effects of a liberal exhibition were soon 
evident, not only in arousing the dormant energies of the nervous system, 
but in checking what little of discharge yet remained. 

For years previous to her death, she had suffered from spasmodic dys- 
phagia, which materially interfered with alimentation, but not less from 
dyspepsia, whenever food of a rich quality was taken. She was also 
troubled with much palpitation of the heart, which from careful examina- 
tion was regarded as functional and sympathetic. These causes had pro- 
duced a sallow, cachectic countenance, and an infirm state of health. 

Nothing unusual occurred in her last pregnancy, until the seventh month. 
Rer dyspeptic symptoms then increased ; respiration on exertion became 
extremely laboured ; palpitation was urgent, and her feet swelled. The 
dropsy did not seem febrile, and the urinary secretion was never deficient. 
Still, as a safeguard, diuretics were freely given, and a few doses pil. 
hydrarg. Hemorrhage, following parturition, was chiefly feared, as she 
was in no condition to bear the loss of blood. 

One month before her expected confinement, without assignable cause, 
she was taken in labour with pains of ordinary character. Shortly before 
the birth, they ceased to be propulsive, yet were agonizing in the extreme. 
The circular fibres of the uterus, acting while the longitudinal were qui- 
escent, no progress was made. Ergot, in moderate doses, was given in 
weak brandy and water, for the triple purpose of regulating abnormal 
uterine action, hastening labour, and guarding against anticipated hemor- 
rhage. Irregular contraction still continued, and twenty-five drops elixir of 
opium were given in brandy and water. By voluntary efforts on her part, 
rather than from efficient pains, delivery was soon effected. Not the 
slightest hemorrhage followed. Respiration, however, was rapid and 
gasping, and it seemed impossible for her to regain the usual equilibrium, 
agitated as her mind was, in view of anticipated flooding. Soon a slight 



1849.] 



Porter's Cases of Premature Labour. 



37 



cough commenced, with frothy expectoration, and both rapidly increased, 
and in consequence she became excessively agitated and alarmed. The 
secretion increasing in the bronchia faster than it could be thrown off, with 
a respiration so panting and crippled, suffocation was imminent. Mean- 
while the uterine pains returned in all their severity, and on examining 
for the placenta, an hour-glass contraction was discovered. The uterine 
pains continued " atrocious," . but voluntary expulsive effort, though fre- 
quently attempted, was impossible, owing to the crippled state of the lungs ; 
the cough and expectoration rather increased, and the scene was truly 
appalling. Throwing herself over on her back, with staring eyes, black- 
ened countenance, and every respiratory muscle in active exercise, she 
whispered, as well as she could, "I am dying." The hour-glass con- 
traction was overcome by manual assistance, and the placenta delivered. 
The cough, expectoration, and difficult respiration continued much the 
same for two or three hours, when it gradually subsided, and she sank 
into sleep. Her pulse from the first had been a mere thread, and her 
countenance pale and ghastly. Stimulants in ice-water, elixir of opium, 
sinapisms, and external warmth, were faithfully applied. On visiting her 
twelve hours after confinement, found her comfortable, had passed water 
freely, — gallons, as some one expressed it, — called for her child, and 
placed it at the breast, and had the prospect of a good night, About mid- 
night, she awoke with a severe pain in her chest, and a feeling of suffoca- 
tion and alarm, but no cough. We were summoned to her — six miles 
distant — at sun-rise, but it was evident that life was fast ebbing. Stimu- 
lants failed to arouse her, and she died within an hour. A post-mortem 
examination was, at this visit, obviously improper, and subsequently, 
owing to distance, it was not obtained. The child, as in the case first 
detailed, died within two days, of cyanosis. It may be proper to state, 
that the effect of position, as recommended by Meigs, was faithfully tried 
in both cases, — the child being placed on its right side, the head and 
shoulders inclined upwards, on pillows, &c. 

Ought the cause of death, in this instance, to be referred to some ob- 
scure cardiac affection ? — or, rather, from the frothy expectoration, difficult 
respiration, and subsequent immense discharge of urine, may we not refer 
it to oedema of the lungs, in connection with the albuminuria of pregnancy? 
If so, a rupture of the air-cells occurred during the violent propulsive 
efforts of the last stage of labour, the final result, however, occurring not 
so much through apnoea as asthenia, or exhaustion. Our object, however, 
is not to speculate, but to propound practical conclusions, which have 
pressed themselves upon our attention. 

Succeeding her two previous confinements, there was alarming hemor- 
rhage. In both cases ergot was given : in the first, at the occurrence of 
the discharge, and in the other, previous to the birth of the child, as a 
preventive measure. Its action was not happy — depressing the system, 
while it did -not check the discharge, Other means, it is true, were 
used, such as acet. plumb., cold friction, &c. Stimulants were used 
sparingly — too sparingly. And here, practice, which is regarded as 
equally sound, sanctions both a free, and a more guarded use. A very 
judicious physician, on being called in consultation to such a case, we 



38 



Porter's Cases of Premature Labour. 



[Jan. 



have heard say, — "Don't give stimulants, for although they may remove 
faintness, yet they will arouse the circulation, and we shall have a renewal 
of the hemorrhage." And such reasoning is apparently sanctioned by the 
highest authority. Hunter says, that the faintness which comes on after 
hemorrhage, instead of alarming the bystanders and inducing them to sup- 
port the patient by stimuli and cordials, should be looked upon as salutary, 
as it seems to be the method which nature takes to give the blood time to 
coagulate. In this connection, we ought to mention the experiments of 
Hewson, designed to show "that the disposition to coagulate was increased 
in those cases where the vital powers were weakened by previous hemor- 
rhage." " Believing that it would be sufficient, for this purpose," says he, 
"to attend to the properties of the blood, as it flows at different times, 
from an animal that is bleeding to death, I therefore went to the markets 
and attended the killing of sheep, and having received the blood into cups, 
I found my notions verified. For I observed that the blood found in the 
vessels, immediately on withdrawing the knife, was about two minutes in 
beginning to coagulate; and that blood taken later, or as the animal became 
weaker, coagulated in less and less time, till at last, when the animal be- 
came very weak, the blood, though quite fluid, yet had hardly been received 
into the cup before it congealed." Both these authorities are, rightfully, 
as we conceive, in favour of withholding stimulants in the early stages of 
hemorrhage. It was under the influence of these principles, however, 
that in this and other cases, we can see that they were too tardily adminis- 
tered. If they do not operate as direct haemostatics, they arrest the patient 
from the most alarming prostration. So grateful are they, at the proper 
crisis, that the countenance brightens, and the whole case assumes a new 
aspect, and if coagulation has but taken place in the uterine vessels, there 
is no further danger of thereby renewing the hemorrhage. The wisdom 
of the wisest has left us the inspired direction, — "Give strong drink unto 
him that is ready to perish." 

Another consideration, has reference to the depressing effects of ergot 
on certain constitutions. In ordinary cases, where the strengh is sus- 
tained, and the system entonic, this property need not be regarded, nay, it 
may even be advantageous to the patient, as preventing subsequent inflam- 
mation. Rejecting the theory of specifics, our remedial agents have only 
a relative value. Ergot, if administered in an atonic condition of the sys- 
tem, with languid circulation, and great, mental or nervous depression, not 
only still further prostrates, but ceases, in no small degree, to have its spe- 
cific action on the uterus. This observation is not new, but has never been 
sufficiently enforced. Under these impressions, although in the case be- 
fore us it had utterly failed, in former labours, to prevent or suppress 
hemorrhage, yet being unwilling to be deprived of its reputed powers, it 
was also given on the latter occasion, previous to parturition, but accompa- 
nied with brandy. While it failed entirely in exerting its reputed power 



1849.] 



Porter's Cases of Premature Labour. 



2d 



as a regulator of abnormal uterine contractions, it prevented all hemor- 
rhage, which, in the weak state of the patient, was much to be dreaded. 
Other cases have since enforced the utility of giving it on some occasions 
with brandy, or other stimulant, or of administering the tincture in prefer- 
ence to the infusion. 

Case III. — The patient, the mother of one child, and for many years 
not pregnant, became so about the middle of September. The symptoms 
were normal, with the exception that the breasts became enlarged unusually 
early, and the size of the abdomen, from two months onwards, was full 
six weeks in advance of what is ordinary. 

Nov. 27th. After slight exertion she was taken with moderate flooding, 
which ceased in three days. She but partially, however, recovered her 
usual health, and from this time she was seriously affected with cramps of 
the lower extremities, and lameness; also with a sense of abdominal heat, 
fullness, and distention, and during some part of her pregnancy, could 
scarcely stand erect. 

Dec. \lth. A slight hemorrhagic discharge, followed by pains in the 
back, &c. The former soon ceased, the pains in the back continuing, and 
appearing much like a menstrual nisus. After two days, there was the 
discharge of eight ounces of dark, grumous, yet uncoagulated, blood, which 
continued two or three days. Immediately after this, her uncomfortable 
feelings left her, for a time, to return in just one month. 

Jan. 17th. Much more unwell: pains in all parts of the system, espe- 
cially the back; cramps and lameness, especially after rising from bed, to 
which, by her uncomfortable feelings, she is forced almost constantly to 
resort. 

30th. Quickened, and from this time, motion was strong and fre- 
quent. Size unusual ; and she was hence a burden to herself. She also 
suffered much from "colic pains." 

March 4th. In this state of things, by accident, she was subjected to 
great agitation and alarm, and under its influence was seized with what 
she supposed severe flooding. The discharge was large, and yet there was 
no faininess or blanching of the countenance. On examination, so much 
water was found mingled with the blood, that it would not stain the finger. 
From the smell, &c, it was supposed to be the waters of the ovum. In 
nature substantially the same, the discharge continued for six days, quite 
profuse, and afterwards in less quantity. The uterus, which by the force 
of contraction had been depressed below the umbilicus, then rose to the 
position occupied before the discharge. Child's motion strong; general 
strength not diminished ; pulse and countenance nearly natural. As the 
discharge diminished, it became of a brownish-red, with a slightly offensive 
odour. From its long continuance, and her confinement, her health ulti- 
mately required the free use of port wine, &c. Astringents were power- 
less over the discharge. 

15th. Discharge continues pale, and has a faint, nauseous and sickly 
odour. Patient distinguishes two kinds of uterine contraction: one, 
which is painless, yet cramp-like ; the other, more like colic, beginning at 
the left side, and shooting down to the right thigh, where it is most severe. 
It is the former which is attended by a gush of fluid ; the latter, she had 
for some days before there was any discharge. There are evening parox- 
ysms of fever; muscular twitchings ; intense burning in the feet and hands, 



40 



Porter's Cases of Premature Labour. 



[Jan. 



and other symptoms of irritation, usually denoted by the term hectic. 
Is very nervous and excitable. 

llth. Discharge pale; great sense of internal distention. Is constantly 
in pain, chiefly in the back ; very lame in the lower extremities. 

19///.. Discharge more pale, but very profuse ; wets a towel thoroughly 
every hour. Sometimes after exertion, a drop of pure blood is apparent 
upon, and mingled with, the water; quantity of urine much less than 
natural. 

2Qth. Contractions more violent, and a pint of fluid was thrown off 
almost in a gush ; very nervous, but unwilling to take a quietus. 

2 1st. Watery discharge strongly coloured with blood, profuse all night, 
wetting four sheets in all parts, — probably about two quarts; alternate 
pains; no faintness or extreme exhaustion. Hoping that labour was ad- 
vancing, an examination was made: uterus and vagina excessively tender; 
os uteri not open, but soft and dilatable; uterus protruding, in a rounded 
form, into vagina. To day took a large dose of laudanum, to quiet alter- 
nate pains, which were effecting nothing towards throwing off the ovum ; 
rested well all the following night, the discharge continuing. 

22d. Pains returned; laudanum has no effect in quieting them; dis- 
charge much diminished. A foetus of the sixth month rapidly descended, 
(the membranes broken,) and was soon delivered, perfect in form and 
vigorous, and survived two days. No unusual discharge occurred at the 
birth ; lochia natural; after-pains few, and recovery rapid. 

Just before the birth of the child, there were protruded from the vagina 
two portions of a yellowish, or fawn-coloured substance, vesicular, and 
feeling like pulmonary tissue, each the size of a goose egg. On minute 
examination, they were found cellular in composition, consisting of round 
and oval cysts, or cells, which were of various sizes, from a pin's head to 
a hazelnut, and united by intervening coagulated lymph. Subsequent to 
the birth of the child, there were two or three slight discharges of a simi- 
lar appearance, but not more than three or four ounces in all — transparent 
and coming in gushes. 

May 1st. Uterine hemorrhage quite profuse for two days, but was 
speedily checked by ergot, tannin, and sulp. teris. Omitting the tannin, 
the ergot and iron were continued for ten days with the happiest effects. 
Subsequently there were two small watery discharges, followed by yellow, 
purulent matter, which, after a short continuance, subsided, leaving the 
patient in ordinary good health. Was this purulent discharge the debris 
from portions remaining in the uterus, and which were thus expelled under 
the influence of ergot? 

Until parturition, the source and origin of the discharge were obscure. 
At first, it was supposed to be the liquor amnii, from a rupture of the 
membranes ; at other times, the fluid collected between the amnion and 
the chorion, or the chorion and the decidua. But its quantity soon dis- 
pelled the illusion. Dr. Davis refers to the escape, in dribbling quantities, 
of an aqueous fluid, similar to the liquor amnii, for weeks and months be- 
fore the accession of labour, and which is a dangerous affection. Churchill 
also refers to the discharge of a watery fluid from the vagina in preg- 
nancy, persisting for weeks and months, and varying from a few ounces 
to some pints a day, and which, he supposes, may have its seat in the 



i84y.j 



Sorter's vases oj Premature Labour, 



41 



lining membrane of the vagina, or in the space between the chorion and 
the amnion. 

A case resembling the foregoing, in some respects, is recorded in this 
Journal (vol. ii p. 522, new series), by Dr. Leonard, which, also, though 
alarming in appearance, terminated favourably. May not the source of 
the discharge in his case, and others of like character, have proceeded 
from vesicular or hydatidic formations, which were overlooked at the time 
of the birth of the foetus ? 

The event shows, conclusively, that the watery secretion had its origin 
in the vesicular bodies, which may, perhaps, be styled clustered hydatids, 
or vesicular mole, and which were thrown off early in labour. It is not 
our design to enter upon the subject of uterine hydatids. The substance 
in question is accurately described by Baillie, in his morbid anatomy, who 
considers them not as acephalocyst hydatids, but as attached cysts. They 
are an instance of the development of new tissues, being composed of 
serous cysts, which, so long as they are connected with the uterus or the 
placenta, continue to secrete water, and this finally stimulates the uterus to 
contraction, by which it is expelled. The uterus relaxing, more fluid is 
secreted, and this process continues until, through exhaustion of the sys- 
tem, or the existence of endo-uterine irritation, caused by the presence of 
air admitted through the ruptured membranes, or through the influence of 
alternate uterine contraction and relaxation, labour is at length induced, 
and the fetus and the mole are simultaneously expelled. 

Its attachment cannot be definitely settled. Probably, however, it ac- 
companied the ovum into the uterus, and may have been attached to the 
placenta. Cruveilhier mentions a case where something of this nature 
was thus attached, and which was, in bulk, nearly equal to the placenta. 
That the waters, in the foregoing case, issued from within the membranes 
would seem probable, from the fact, that there was no known rupture of 
them at, or shortly preceding, the birth, — the discharge having almost 
ceased for six hours previous to labour. 

The foregoing case disproves the assertion of Rigby (p. 114), that these 
vesicular masses are invariably connected with a blighted ovum. In strong 
constitutions, with little irritability of fibre, they may, possibly, co-exist 
with pregnancy quite up to the full period. On the other hand, in the 
more delicate, this diseased condition of the ovum and its membranes 
may be the unsuspected cause of frequent early abortions. 

New London, Ct., Sept. 1848. 



42 Fox's Report of Cases treated in Pennsylvania Hospital. [Jan. 



Art. VIII. — Report of Cases treated in the Pennsylvania Hospital. By 
George Fox, M. D., one of the surgeons. 

Case I. — Ununited Fracture of the Femur. Seton continued during 
four months without benefit. — imputation. 

E. F., set. 33, married, from New Jersey, was admitted 30th of March 
last, with an ununited fracture of the left femur. She states that she 
received the injury on the 3d of August, 1847, in falling from a swing, that 
the end of the upper fragment protruded slightly through the soft parts, 
which wound, however, healed by the first intention, that the fracture was 
treated with Hagedorn's splint, and after the first week, four short splints 
were also applied, bound tightly round the thigh ; this treatment was per- 
sisted in till the end of February, when no union having taken place they 
were removed, and pressure tried, also, without effect, until she was brought 
to the city and admitted into the hospital. At this time the limb was 
enormously swollen, and very movable at the seat of the fracture ; the 
fragments appeared to be overlapped and separated considerably ; by ele- 
vating the foot and throwing the limb outwards they were brought into nearer 
contact. Under these circumstances splints were adapted to the limb, and 
so arranged as to keep the fragments as closely as possible together ; rest 
and compression were again resorted to and continued three months. 
Finding at the expiration of that time bony union had not taken place, it 
was determined in consultation to use the seton, as recommended by Dr. 
Physick — which I accordingly introduced on the 24th of June. No undue 
inflammation at any time supervened, though upon several occasions there 
were slight erysipelatous inflammation and considerable suppuration; the 
limb was placed in as good position as possible, and after a few weeks a 
splint made of gutta percha, well padded with cotton, carefully applied ; 
this was worn some weeks, but removed as she seemed more comfortable 
without it. The seton was persisted in till the 29th of October, when finding 
it had produced no good effect, it was withdrawn. On the 15th of No- 
vember amputation of the thigh, above the seat of fracture, was performed 
by Dr. Norris. 

Case II. — Compound fracture of the Humerus — Extensive Laceration 
of Soft parts — Amputation at Shoulder-joint. 

Henry McGuigan, set. 43, married, labourer, was admitted June 28th, 
with a compound comminuted fracture of right humerus, extending nearly 
to the head of the bone, with extensive laceration of the soft parts, caused 
by the passage of a train of burthen cars over it. The nature and extent of 
the injury was such as to demand immediate amputation at the shoulder- 
joint; reaction being fully established, I at once performed the operation. 
The flap was formed of the deltoid, the artery was readily controlled by 
pressure, with a key upon it as it passes over the rib. The patient was a 
large, muscular man ; as the division of the lower portion was being made, 
by a slight involuntary motion of his body he displaced the position of the 
key, causing at the moment considerable hemorrhage ; this was soon 
checked, the vessels secured, and the wound dressed with adhesive strips, 
charpie and bandages — an opiate administered, and directed to be repealed 
if requisite ; diet confined to gruel, tea and bread. 

July 1st. — Removed and reapplied strips ; water-dressings now directed ; 
adhesion by first intention of part of the wound. 



1849.] Fox's Beport of Cases treated in Pennsylvania Hospital. 43 



18th. — Ligature of axillary 'artery separated to-day. There has been 
and still continues very free suppuration ; the water-dressings continued. 

20th. — Suppuration diminished ; union going on well ; he is now al- 
lowed to get up and has house diet. 

Aug. 25th. — Discharged well. 

Another amputation at the shoulder-joint was performed by my colleague 
Dr. Peace, on the 23d of May, on a boy, Robert Simpson, set. 12, who re- 
ceived a similar injury of the left arm, from being caught in machinery. 
In this case the flap was also made of the deltoid; nothing unfavourable 
occurred during the progress of the case, and on the 22d Ju]y he was dis- 
charged well. 

Case III. — Compound Comminuted Fracture of Skull — Removal of a 
large portion of Right Parietal Bone — Recovery. 

James Stafford, set. 21, native of Ireland, was admitted early in the 
morning of 23d of July. The evening previous, whilst engaged in dragging 
a fire engine, he received a severe injury of the head, caused by a brickbat, 
thrown from the roof of a house, striking him as he passed. The external 
wound, situated on the top and right side of the head, is irregular and con- 
tused, fracture with depressed bone evident; it is stated that immediately 
after the injury he was completely insensible ; some hours elapsed before 
he was brought to the hospital ; soon after his admission his skin was 
warm; pulse from 110 to 120, feeble and not perfectly regular ; pupils 
natural ; sight good ; lays in a semi-stupid state ; can, however, be roused 
without much difficulty, then complains very much of pain in the head, 
and moans constantly. There is also complete paralysis of the left side; 
he is directed to be kept perfectly quiet ; head to be elevated, and water 
dressings applied to the wound; a purgative administered ; and barley water 
only allowed as nourishment. In the evening, in consequence of febrile 
excitement, he was bled ^xvij. 

24/A. Has passed a restless night; pulse 126; skin warm; bowels 
freely operated on; complains of pain in the head. At 11 A. M. we 
proceeded to elevate the depressed bone. Having enlarged the external 
wound to the extent of five inches, we found the fracture more extensive, 
and depression greater than we had supposed, a surface of from two and a 
half to three inches of the right parietal bone being much comminuted and 
driven in upon the brain ; a small projecting portion of bone was removed 
by Hey's saw, which enabled us to get at and remove all the pieces of 
bone (seven in number). The dura mater was wounded in three places, 
from one of which, an inch in extent, cerebral matter escaped ; there was 
considerable hemorrhage from the middle artery of the dura mater; after 
this ceased, the external wound was brought together with two sutures and 
adhesive strips, and dry lint applied for the present. 

3 P. M. Pulse 120 ; skin warm ; slight delirium and restless ; no re- 
lief of paralysis. Directed lint wet with cold water to be kept constantly 
applied to the head, room darkened, and strict quiet enjoined, iced barley 
water only allowed. Midnight. Without material change ; pulse 104. 

25th. 11 A. M. — Had a restless night ; dozed a little ; he is perfectly 
conscious and intelligent; and gives a clear account of the accident; pulse 
92; bowels open during the night ; complains much ; and moans constantly. 

7 P. M. Pulse 98; slight erysipelatous inflammation of right side of 
head and scalp. 



44 Fox's Report of Cases treated in Pennsylvania Hospital. [Jan. 



2Qth. 11 A. M. — Passed another restless night; still moans and com- 
plains of pain in head and neck ; wound suppurating slightly ; some brain- 
like matter is also discharged; pulse 104; skin pleasant; bowels open; 
continued cold applications to the head ; and iced barley water as nourish- 
ment. 

27th. Rather quieter last night; pulse 88; skin pleasant; intelligence 
good; though at times there is slight delirium, particularly when first awak- 
ened ; still complains greatly of his head ; directed blisters to be applied 
to the inside of the calf of the legs, and | grain of calomel three times a 
day. Tapioca and gruel in addition to the barley water. 

28th. Had a violent convulsion during the night which lasted nearly an 
hour; his blisters had drawn well at the time. This morning his pulse 
is 104, and intelligence good: the discharge of brain-like matter continues, 
with slight suppuration from wound. 

29th. Intelligence good; occasional delirium; pulse 84; same character 
of discharge from wound. 

30th. Complains of being very weak ; pulse 90 ; is allowed mush and 
milk ; cold water dressings continued. 

31st. Stitches removed; is allowed weak mutton broth in addition to 
the other diet. 

Aug. 1st. Not so well; had a chill last evening, which, it is feared, is 
the precursor of more unfavourable symptoms; is very cross, and at times 
delirious; skin hot; pulse 112, and more feeble; tongue furred; some 
tympanitis ; wound suppurating, and upon pressure an oozing of sanious 
brain-like matter. Directed an enema containing ^ss ol. terebinthinae, — 
continue calomel and cold water dressings ; diet to be again restricted to 
farinaceous articles. 

2d. Much better ; had a quiet night ; pulse 92 ; skin pleasant. 

3d. Passed a good night ; intelligence perfect ; says he feels pretty easy, 
though very weak ; pulse 80 ; tongue clean and moist ; slight ptyalism ; 
the calomel is now omitted, and he is again allowed mutton broth, mush 
and milk, and ice cream. 

10th. Intelligence perfect; pulse 74; skin natural; appetite good; 
paralysis continues the same ; bowels opened daily by enemata ; appearance 
of wound healthy, and cicatrizing. Continue cold water dressings and 
same diet; the mercurial influence is also kept up. 

19th. Condition much the same; the paralysis continuing; a blister is 
directed to the nape of the neck ; to be kept discharging. 

24th. To-day can flex his left leg, though he cannot extend it or move 
his toes ; left arm still motionless ; in other respects gradually improving ; 
blister still sore. 

30th. Moves his arm, though he has no power over his fingers or toes ; 
blister to nape of the neck was reapplied on the 28th. 
Sept. 4th. Moves his toes. 

1th. Can walk with assistance ; blister reapplied yesterday. 

12th. Walks with the assistance of a chair; he is up nearly all day; 
continue same diet, &c. 

Oct. 2d. Wound cicatrized ; he has nearly regained the perfect use of 
left leg ; the arm also improves. 

Qth. Discharged from the hospital well, excepting slight paralysis of 
left arm. 

18th. Walked to the hospital to see us. His health is good; scarcely 
anything to be noticed in his walk ; arm much improved. 



1849.] Fox's Report of Cases treated in Pennsylvania Hospital. 45 
Case IV. — Gunshot Wound of Thorax: Death. 

John Hayes, an Irishman, aged 27, a coachman by occupation, was 
brought into the hospital on the 26th of Oct., with a gunshot wound of the 
thorax. He was said to have lost a good deal of blood from the wound, 
which was made by a pistol ball ; as he lay upon his back, however, when 
brought in, no blood came from the orifice. The surface was cold, coun- 
tenance a-nxious, respiration oppressed, pulse almost extinct. He was put 
to bed, the upper part of the body elevated, mustard plasters and artificial 
heat applied to the extremities, and brandy and water administered to him 
freely. The opening made by the ball was two-thirds oi an inch in dia- 
meter, and was distant one inch and an eighth from and on a level with the 
left nipple, and to the right of it, its edges blackened and ragged. At every 
act of respiration the air passed to and fro through the orifice with a whis- 
tling noise. No attempt was made to search for the ball, or determine by 
instrumental means the nature of the lesions it had produced within the cavity 
of the chest. Adhesive plaster was placed over the wound, and upon this, 
lint and muslin soaked in the ethereal solution of gun cotton was placed. 
Upon drying this adhered firmly over the aperture, effectually preventing 
the further introduction of air through it into the thorax. A broad roller 
was then passed around the chest and secured firmjy. The left side of the 
chest was very resonant upon percussion, but the respiratory murmur could 
not be heard at any part of it. The latter was somewhat increased in 
loudness upon the right side. In about an hour after the assiduous use of 
internal and external stimulation the pulse rose, the surface became warmer, 
and the oppression of the patient diminished slightly. The sound of respi- 
ration could then be heard upon the left side and mingled in its lower half, 
with a moist rhonchus and a very distinct metallic tinkling. The impulse 
of the heart was feeble, and its sounds diffused and indistinct. He had no 
expectoration of any kind. 

In the evening he seemed very uneasy, continually moaning, but com- 
plained of no pain except in the small of his back ; yet to this symptom he 
constantly called attention, seeking earnestly for relief. He was ordered a 
drachm of the solution of morphia, to be repeated every two hours, and bar- 
ley water as a drink. At eleven, P.M., his general condition and the phy- 
sical signs afforded by the chest, continued the same. As he was unable to 
pass his urine, the catheter was introduced and a pint of urine drawn off. 

He slept a little during the night, and was found in the morning some- 
what better; his skin was warm, his pulse 120 and feeble, but he was less 
anxious, and the dyspnoea had diminished. The left side of the chest was 
now less resonant upon percussion ; the metallic tinkling could still be heard, 
though not so distinctly upon the lower portion of this side in front. The 
abdomen was somewhat tympanitic, and the muscles of it rigid. He passed 
his urine himself. 

Directed to continue the morphia. At ten o'clock he was ordered Dover's 
powder three grs., calomel one gr., to be taken every two hours; and his 
diet limited to arrow root. During the day his pulse rose in frequency, 
and was extremely feeble, but late in the evening it sank again to 120 beats, 
and became full and resisting. He was now bled from the arm to the ex- 
tent of fifteen ounces, after which it became softer and he seemed to expe- 
rience a slight relief from the dyspnoea. His urine was again drawn off 
by the catheter, as he was unable himself to void it. He slept at intervals 
during the night, and in the morning his skin was warm and perspiring, 
pulse 120, and feeble. His countenance still wore an expression of great 
anxiety, and he complained bitterly of the pain in his back. His dyspnoea 
No. XXXIII.— Jan., 1849. 4 



46 Fox's Report of Cases treated in Pennsylvania Hospital. [Jan. 



was greater than before. Respiration could be heard in front over the 
greater part of the left side, and the moist rhonchus and metallic tinkling 
were still audible. The powders were discontinued. During the day he 
seemed to be growing feebler, and his abdomen became very much distended. 
Attempts were made to relieve this distension by the introduction of an 
elastic tube into the bowels, by the injection of turpentine enemata, and by 
turpentine fomentations over the abdomen ; but no gas escaped through 
the tube, the injections were forcibly expelled, and the fomentations failed 
to relieve him. His stomach became also intolerant of all ingesta, fluid or 
solid, both being rejected as soon as taken. 

He died at eleven, P. M. of the 28th, sixty hours after his accident, and 
retained his senses perfectly till the last moment. 

The body was examined eleven hours after death. 

The surface was pale, some discoloration posteriorly, the muscles very 
rigid. On the left side of the chest one inch and an eighth to the right of 
the nipple, and in a line drawn from it to the median line, an opening was 
seen communicating with the interior of the chest. 

In dissecting the muscles from the thorax, the external wound was found 
to correspond with one between the fifth and sixth ribs, slightly grazing 
the fifth. Blood was extravasated in the intercostal muscles in its neigh- 
bourhood. The left lung was found collapsed, and the cavity of the left 
pleura was half filled with blood partly coagulated and partly fluid. A 
leaden bullet weighing a fourth of an oz., was found in this cavity, as well as 
some shreds of clothing. The pericardium contained a large quantity of 
coagulated blood and was perforated at that portion corresponding to the apex 
of the left ventricle, with two orifices distant from each other about an inch 
and a half. The internal surface of the pericardium was lined by a delicate, 
newly organized false membrane. The heart was firm, and the left ventri- 
cle somewhat hypertrophied. On this ventricle near the apex of the heart 
there was a furrowed wound an inch and a half long, and half an inch 
wide, which led from one of the orifices in the pericardium to the other, 
but did not communicate with the cavity of the heart. It was not possible 
to discover any wound of the substance of the left lung; it could be com- 
pletely inflated with air and continued to retain the form given to it by the 
inflation, until the air was allowed to escape through the left bronchus. Be- 
tween the lobes of the lung, however, when the lungs were filled with air 
and in a line corresponding to the wound of the heart, several patches of 
blackened membrane, easily detached, were found, which seemed to indicate 
the passage of the ball after leaving the pericardium. There was no lesion 
of the diaphragm or stomach. The intestines were found to be distended 
with gas, but otherwise they, as well as the peritoneum, were in a perfectly 
normal condition. 

This case was one of much interest. The absence of bloody expectora- 
tion led us to infer there was no wound of the lung, although the other 
physical signs were such as we should have expected to have met with in 
a wound of that organ. I am indebted to my friend, Dr. M. Stille, house- 
surgeon, for the history of the case, and post-mortem. 

Two cases of aneurism, one inguinal, the other carotid, came under treat- 
ment during my term of service. In the former a ligature was applied to 
the external iliac ; in the latter to the primitive carotid. Both cases are 
progressing favourably; we will give the details of them in a future number. 



1849.] 



Hartshorne's Notes of Hospital Cases. 



47 



Art. IX. — Notes of Hospital Cases. By Henry Hartsiiorne, M. D. 

Bronchitis with Fetid Expectoration. John Robinson, aged about 
thirty-five, a large, square built man, but then very thin, was admitted into 
the Pennsylvania Hospital 6 mo., 1846. He had had a cough for several 
weeks, and complained of great debility, but no pain. His expectoration 
w r as very copious, ash-coloured, and of an extremely offensive odour, 
almost fecal. 

This symptom naturally induced the suspicion of gangrene of the lung ; 
but physical examination by Drs. Pepper and Gerhard, discovered no signs 
of this. There was no dullness on percussion, no bronchial respiration, 
nor bronchophony. 

iodide of iron and good diet were prescribed. 

7 mo., 3d. He has improved in all respects. 

llth. Still continues better. 

Ibth. His cough and expectoration have almost disappeared; strength 
and general condition have also greatly improved. He has been using for 
some days tinct. cinchon. comp., in addition to the liq. ferri iodid. The 
case must have been one of bronchitis only. Dr. Pepper has observed a 
similar expectoration in a few other cases of bronchitis. 

Gangrene of the Lung. This was observed in an Italian sailor, named 
Calichi, in the winter of 1847. 

The attack appeared to have begun as ordinary pneumonia; it had, how- 
ever, progressed considerably before he entered the house. The degree of 
fever, pain, &c, indicated antiphlogistic treatment; and moderate venesec- 
tion, cupping, and mild mercurials and opiates, were used. The expecto- 
ration was at first rusty and muco-purulent ; afterwards approaching pure 
blood; and finally dark, with the odour of putrefaction. He then became 
prostrate, and died about five days after admission. Post-mortem inspec- 
tion displayed the complete sloughing of one lung. 

Apparent Syncope in Bronchitis. — This, probably a not unfrequent 
symptom, I observed first in the early stage in one of the nurses ; who, 
while requesting advice for a very severe cold which affected his chest, 
accompanied with pain in the head, fell at full length on the floor. He 
was treated by venesection, purgatives and expectorants, and soon recovered. 

A young sailor was not long after admitted, with recent bronchitis, in 
whom the same thing occurred. Finding that the pulse was not greatly 
reduced, as in common syncope, I bled him at once from the arm, with a 
favourable result. Oppressed respiration, causing an oppressed circulation, 



•18 



Hartshorne's Notes of Hospital Cases. 



[Jan. 



and deranged supply to the brain, must have caused the sinking, which, in 
appearance, was exactly like the fainting of debility. 

Bronchitis treated by Inhalations. — Advantage was derived in several 
chronic cases, during Dr. Pepper's term, from the inhalation for a few 
minutes, once or twice daily, of a mixture of tinct. digital, and Lugol's 
solution, 3 g s of each, in a pint of water at 100° Fahr. Tobacco fumiga- 
tion, i. e. smoking, by those not inured to it, has been directed for irritable 
lungs with benefit, by my father in private practice. The great attention 
recently given to the subject of inhalations, will undoubtedly develope some 
new results in the management of pectoral affections. 

Tincture of Lobelia in Asthma. — In 12 mo., 1846, three cases occurred 
which evinced the great utility of lobelia as an antispasmodic expectorant. 
They were both instances of asthmatic congestion of the lungs; one of 
them quite severe and threatening. Cups, blisters, and some other deple- 
tory measures, were used in both; but the most signal benefit was repeat- 
edly referred by the patient to the lobelia, in doses of 5 SS of * ne tincture 
every few hours; or even more during the severity of the paroxysm. One 
bore drachm doses without vomiting or other unpleasant effect. The 
remedy was gradually withdrawn when relief was obtained. 

Another instance of its use with success is noted in 2 mo., 1847. 

Tartarized Antimony in Pneumonia, 8fc. — In the Pennsylvania Hos- 
pital the violent contro-stimulant practice is not used; but the tartar-emetic 
is frequently prescribed in non-nauseating doses. By two or three stout 
Irishmen, affected with pneumonia, one-sixth of a grain every two hours 
was borne for several days together; but most generally one-eighth of a 
grain was found sufficient for the proper effect. In one case of chronic 
bronchitis, the continuance of this dose for a week or two induced slight 
gastritis. 

In the winter of '46-7, a number of cases of pneumonia, of which four 
were quite severe and one extremely violent, attacking both lungs, were 
treated successfully under Dr. Wood's direction, by the usual plan of free 
and sometimes repeated venesection, cupping, gentle purgation, and com- 
binations of blue mass or calomel with ipecac, and opium, avoiding saliva- 
tion. In the winter of '47-8 not a single case of pneumonia occurred in 
the wards. 

Gunshot Wound of the Chest. — Lawrence Naulty was brought into the 
hospital, 9 mo., 9th, 1846, having been accidentally shot by the discharge 
of a fowling piece within a few feet of his body. The charge entered 
back of the point of the left scapula, and came out by a more extended 



1849.] 



Hartshorne's Notes of Hospital Cases. 



49 



opening in the neighbourhood of the fourth rib, nearly three inches back 
of the nipple; being thus on the anterior of the axilla. He was said to 
have expectorated blood before being brought there; but no air could be 
perceived to pass through the opening. The pulse and skin showed great 
tendency to collapse. He complained of violent pain. The wounds being 
dressed with lint, he was put under the influence of morphia, which, how- 
ever, did not give sleep or stop his groaning till the next night. 

The prostration and irritation were such as to make necessary the use of 
a catheter for several days. Hemorrhage at the time of the injury may in 
part account for his weakness. 

llth. Considerably less* pain, and countenance better. Reaction has 
occurred. This afternoon the wounds were dressed ; the edges were al- 
ready beginning to slough. The warm water dressing was used — i. e. a 
piece of patent lint doubled, wet with warm water, and covered with oiled 
silk, retained in place by strips of adhesive plaster. 

It is needless to go into detail farther than to state that the case ended 
in complete recovery ; the principal delay resulting from the necrosis of 
large portions of the wounded scapula. The beautiful and complete adap- 
tation to such a case of the water dressing as above described, which was 
continued for many weeks, is the principal matter of note. 

Phosphate of Jlmmonia in Rheumatism. — This remedy was fairly tried 
by Dr. Pepper in the spring of '46. It was given in doses of ten to thirty 
grains in acute and subacute rheumatic cases. It was not found to justify 
the theory of Dr. Buckler, of Baltimore, who believed it to have specific 
powers, by a chemical agency: but patients recovered under it, though not 
rapidly, so as to convince me that it might prove a useful adjuvant, and 
sometimes, substitute for colchicum. Its alkaline composition, and laxative 
action, are sufficient to account for this. In 1847 one case at least occurred 
in which its use was followed by recovery, where the attack had resisted 
other plans of treatment. In some patients diarrhoea, and in others nausea, 
was produced; but generally it seemed a mild remedy. The vehicle pre- 
ferred was aq. cinnamom. 

The curative power of colchicum was found to be far from infallible. In 
some, aided by depletion, its effect was immediate; others were scarcely 
improved while taking it even for weeks. 

Calomel and Opium in Rheumatism.- — Several cases occurred, particu- 
larly during the winter terms, which showed a controlling power in the 
mercurial impression. But a speedy and violent relapse in one on leaving 
the house in fine dry weather, tended to confirm a remark made by Dr. 
Gerhard, that rheumatic cases treated by mercury are apt to be left in a 
state more susceptible to relapse than after the use of other remedies. In 
some instances also it failed to relieve. 



50 



Hartshorne's Notes of Hospital Cases. 



[Jan. 



The conclusion of the writer is, that this treatment should be avoided 
unless in syphilitic cases, or as a last resort where other remedies have not 
succeeded. 

Quinine in Rheumatism. — Shepherd, a female patient, suffered for a 
long time under succession of attacks of great violence and intensity. No 
management seemed to arrest them more readily than the administration 
of quinine, 12 or 15 grains daily. Another woman in the same ward, 
with an attack of a few days' standing, decidedly inflammatory, with red, 
swollen and tender joints, and some fever, though a rather feeble diathesis, 
recovered almost at once when " quininized." 

Hot Bathing in Chronic Rheumatism. — Many sufferers from chronic 
rheumatism, unmitigated by medicines, were entirely cured in the winter 
by the use daily of a bath at 102° Fahr. During the summer terms, fre- 
quent and free cupping, dry or wet, to the spine was attended with great 
benefit, even when the pains were only in the limbs. 

Death apparently from Metastasis . — Benjamin Pascall, a coloured man, 
45 years old, had pain frequently in two places in the back for 14 years. 
Entered the hospital for an attack of acute rheumatism in his limbs, with 
also a slight cough. Being cupped, purged with Scudamore's mixture, 
and treated by vin. colch. rad. with magnesia, and a blister to the back 
dressed with morph. acetat., he recovered so far as to propose leaving. 
Before doing so, however, he caught fresh cold by an accidental exposure, 
and was again attacked with pain and fever. The feet were swollen, 
exquisitely tender and painful; he asked for a blister; one was applied, — 
and gave considerable relief. He then begged for something of the same 
kind to the other foot. Being somewhat doubtful as to its propriety, I 
began with a sinapism a little larger than a dollar. This partially eased 
the pain, and the next night at his request I applied a larger one, over the 
whole instep. 

5th mo. 24th. At ten in the morning, he had a shaking chill, with com- 
mencing pain in the right hypochondriac and epigastric regions. A large 
sinapism was then applied to the epigastrium, and dry cups were placed 
upon the back. 

In the evening he was worse: with a great deal of pain below the margin 
of the ribs, skin rather cold, breathing hurried, pulse rapid and feeble. The 
day before he had had several passages, but to-day was constipated. He 
vomited several times. Tinct. rhei et sennae ^ss every hour for two or 
three hours was directed, followed by an opiate. A blister was also placed 
over the epigastrium. The pain continued. 

The next morning at 5 o'clock the prostration was greater, although 
the pain was less severe. The feet being very cold, they were placed in 



1849.] 



Hartshorne's Notes of Hospital Cases. 



51 



hot water. The blister did not act, and a sinapism was again substituted; 
ammonia and wine whey were directed. 

During the same morning, contrary to urgent advice, he persuaded his 
friends to carry him home on a settee. He died there about an hour after. 
No post-mortem examination could be obtained. 

Had the rheumatic attack here suddenly fallen on the abdominal viscera ? 
There was no sign, physical or rational, of the heart being at all affected ; 
and the pain was not constantly localized in the stomach. 

Was it possible that the application of a blister and mustard plaster to 
the affected extremities during the existence of rheumatic fever had any 
thing to do with the extension or transfer of the disease to vital parts ? 

I have understood that his former physician had thought him for a long 
time to have suffered from disease of the kidneys; and Dr. Pepper con- 
sidered it very possible that an abscess of one of them, rupturing into the 
peritoneal cavity, may have caused his death. 

Iodide of Potassium in Syphilitic Rheumatism. — The large number of 
sailors admitted on the custom house list with this complaint renders it 
easy to test remedies with it ; and this experience shows, that the above 
medicine, in moderate doses (gr. x ter die), acts as a specific upon it — 
often relieving the nocturnal pains in the bones in a few days, — and favoring 
the disappearance of nodes. Several such cures I have noted, and from 
one to two dozen must occur annually in the hospital. 

Syphilitic Iritis, of a violent character, was in a case noted fourth mo., 
1 4th, 1846, reduced only by the mercurial impression. It supervened while 
the patient was taking Donovan's solution on account of an obstinate 
eruption; and the continuance of that remedy, in doses sufficient to nauseate 
(gtt. v ter die), allowed the disease to progress. Three days' use of calo- 
mel (gr. j ter die) with opium and ipecac, caused the return of sight, the 
absorption of lymph, and recovery. Leeches had been previously used. 
A similar result is recorded as having occurred in several other instances. 

Mercury in Syphilis. — Recent clinical lectures in the hospital announce 
that the experience of its wards tends to disparage the necessity or general 
advantage of this medication, so much urged by some older surgeons. 

It has always, however, been allowed in particular cases; and it may be 
merely observed, that the exceptional instances of its use have encouraged 
the opinion of the writer, received from other authority, of the propriety 
of the cautious use of mercury in syphilitic disease. Hydrarg. iodid. 
appears to be perhaps the best preparation for the purpose. The surgeons 
are in the habit of directing it especially in cases of obstinate chancre, 
or where irreducible phymosis prevents local means. Upon these, es- 
pecially thorough cauterization with argent, nitrat., they usually rely. 



52 Hartshorne's Notes of Hospital Cases. [Jan. 

Calomel as a local application in Chancre. — This is a favourite treatment 
in the hospital, in all obstinate chancres, and buboes which will not heal 
after being opened. The powder is sprinkled freely over the surface, 
which is then dressed with lint wet with dilute solution of chloride of soda. 
I have repeatedly noted the most striking results from it, where the black 
wash had entirely failed. 

Phymosis and Paraphymosis in Chancre. — A question may arise at 
a certain stage, which of these conditions is preferable; that is, shall the 
phymosis which is forming be forcibly reduced while a chancre exists on 
the prepuce, or not ? In two cases I saw this done, once by myself, and once 
by the patient's own act, leaving it irreducible ; and the tendency of chancre 
to spread over any abraded or divided surface made the cases so troublesome 
that I should never wish to repeat the change. You may treat a chancre 
under an incompletely phymosed prepuce by injections. Why might not 
a weak solution of corrosive sublimate be more used? Or the black wash, 
and solution of cupri sulph. — relying much also on the internal use of 
mercury, especially in such cases ? 

Venereal Warts. — The most convenient and complete, and least painful 
mode of removing these, was found to be by strong nitric acid, applied 
only to the excrescence. It destroys it so entirely as to cause its separa- 
tion in a short- time, without injuring, if carefully applied, the surrounding 
parts. 

Hemorrhoids cured by spontaneous sloughing. — James Roney, admitted 
fourth mo., 1846, with chronic dysentery, had also suffered for three years 
from hemorrhoidal tumours. They had been always reducible till after 
his admission, when they protruded completely, along with a portion of 
the rectum in a state of prolapsus, — which could not by any effort be en- 
tirely returned. Besides opiates by the mouth and by enema, a poultice 
was kept constantly to the part, at first of ground flaxseed, and then of 
slippery elm and liq. plumb. 

The inflammation and swelling were considerable; and finally the 
tightness of the sphincter ani induced the strangulation and sloughing of 
the tumours, all but one. His pain then diminished greatly, and the parts 
were finally returned. The dysenteric symptoms were altogether improved 
by the change. 

A similar spontaneous cure of piles by sloughing has before occurred 
in the observation of Dr. Norris. 



1849.] Gayley, Etiology of Intermittent and Remittent Fevers. 53 



Art. X. — On the Etiology of Intermittent and Remittent Fevers. — 
By James F. Gayley, M.D., of Philadelphia. 

The etiology of intermittent and remittent fevers has long engaged the 
attention of the profession, but though repeatedly investigated by some of 
the ablest minds, it is still to a certain extent involved in mystery. The 
first who put forth definite views on the subject was John Maria Lancisci, 
an Italian. In a work entitled " De noxiis Pallidum Effluviis," printed in 
1717, he advanced the idea that these fevers were caused by certain marshy 
exhalations, to which he gave the name "miasmata"- — from the Greek 
word jutat'vw, to pollute. But subsequent observation showed that the 
vicinities of marshes and stagnant pools were not the only places where 
the disease was met with. It was found where no marshes existed; and, 
as the Fall of the year was the season when the disease was most prevalent, 
it was attributed to a poison generated in the decomposition of vegetable 
matter. This view was generally adopted by the profession until the 
publication of Dr. William Ferguson's paper "On the Marsh Poison," in 
the Edinburgh Philosophical Transactions for the year 1821. This 
eminent physician, during his connection with the medical staff of the Bri- 
tish army in the Peninsular war, collected many interesting facts on the 
subject. He showed that vegetable decomposition was not necessary to 
produce the disease ; — " that the peculiar poison may prevail where there is 
no decaying vegetable matter, and no vegetable matter to decay ; and that 
for producing the poison all that is necessary is a surface capable of absorb- 
ing moisture, and that this surface should be flooded and soaked with 
moisture and then dried; and the higher the temperature, and the quicker 
the drying process, the more plentiful, and the more virulent, is the poison 
that is evolved'." 

Some have asserted that the miasm is'a halitus from the bowels of the earth 
which escapes through the fissures produced by the warmth of the sun, 
after heavy rains in the summer and autumn months. Facts, it appears to 
me, are constantly met with which none of these theories can explain. Let 
us examine them a little more in detail. 

First: The theory of vegetable decomposition.— -The disease attributed 
to its effects makes it's appearance usually about the first of August and 
continues until about the middle of October, or the appearance of frost. 
This may be taken as the general law, but it varies in different latitudes. 
It is met with again in the Spring, during ihe latter part of April, the whole 
of May, and running on sometimes through the first and second weeks of 
June. Let us trace vegetable decomposition through the same months and 
see if it can be the cause of all this mischief. 

During the latter part of July, the whole of August and the early part 
of September we have very little of it. Even the appearance of decay is 
scarcely perceptible. The grain and hay stubble, the dried stems of plants 
w r hose process of fructification is completed, are all that can be undergoing 
the process then.: — -and they decompose very slowly. In the Spring they 
are often found very little changed ; but after the appearance of the early frost 
in October, the sun coming out warm through the day, life being arrested 
while the stems are succulent, there is a supply of moisture present, and 
the process of decomposition goes on in the day-time with great rapidity. 
If the miasm causing the disease is produced by the decomposition of vege- 
table matter we ought to have it then in a maximum, and the disease in 



54 Gayley, Etiology of Intermittent and Remittent Fevers. [Jan. 



its most malignant form. But is such the fact ? Everybody who has lived 
in a malarious region, as it is called, knows that frost is hailed by the inha- 
bitants as a deliverer. That after a severe frost, the influence of which can 
be felt and seen, the disease is mitigated or entirely arrested. As the Fall 
advances the decomposition of vegetable matter increases, and is kept up 
in southern countries through the Winter. But it is a well-known fact that 
the course of the disease is just the reverse. In April and May nearly all 
vegetable decomposition has ceased. All that can be undergoing the pro- 
cess then are some plants of a very fibrous texture, that have resisted 
the action of nature during the preceding Fall and Winter, and those vege- 
table remains that are now applied as manures, the elements of which are 
soon appropriated by the growing plants to their nourishment. Certainly 
the miasm ought now to be at a minimum. Yet we have at that time, in 
malarious neighbourhoods, a good deal of intermittent fever. 

Dr. Ferguson has given us, in his paper " On the Marsh Poison," many 
instances of the prevalence of intermittents and remittents in places where 
vegetation .was not only absent, but its existence absolutely impossible, 
as along the dried bed of the Guadiana, the dry sandy surface on the 
Alantejo side of the Tagus opposite Lisbon, and a " bare open, hollow 
country like the dried up bed of an extensive lake" near Ciudad Rodrigo. 

But the decomposition of vegetable matter goes on abundantly without 
the production of the miasm. " The rotting cabbage-leaves of Covent 
Garden, and those which taint the air of the street from the neglected dust- 
holes of London, during the hot weather of Summer, give rise to no ague. 
The same may be said of the putrefying and offensive sea-weed, which is 
deposited in large quantities upon some very healthy parts of our sea-coast" 
[Watson's Practice, p. 454). 

In the west of Ireland the farmers are in the habit of collecting the algae 
along the sea-coast, every year, and spreading it over their farms as manure. 
This is done in the months of July and August, when the temperature is 
highest. It undergoes decomposition very rapidly, emitting a most abomi- 
nable stench. A gentleman who spent some time at a watering place near 
Ballyshannon, a few years ago, informed me, that he has seen the fields 
covered with it for miles; yet no intermittents follow. The same fact has 
been corroborated by another gentleman, now at Princeton College, whose 
father owns property along the north-west coast of Ireland. 

Sir James Clarke, in his work on the sanative influence of climate, says : 
"It is remarked in the statistical reports on the health of the navy, that on 
the South American station there are land-locked harbours, where, under 
a powerful sun, ships lie for months, or years ; surrounded by a country 
abounding in marshes and rank vegetation and all the other circumstances 
which elsewhere are considered the essential cause of the fevers which prove 
so destructive of life among Europeans, without the occurrence of a single 
case of fever. The crews on the contrary enjoying good health." — (p. 171, 
Philadelphia ed.) 

"The town of Point au Petre in Guadaloupe is situated among the 
most putrid marshes in the world, the stench of which is never absent from 
the streets ; yet the place is far from being uniformly unhealthy. Stran- 
gers, though much annoyed by the smell, often resorted to the place with 
impunity." [Ferguson on Marsh Poison, p. 10.) 

There is " a large cess pool to the windward of Belfast (Ireland), which 
is the reservoir of several sewers from neighbouring streets, from a house 
of correction, a lunatic asylum, and from a great number of cotton factories, 
a distillery, and other extensive sources of aiiimal and vegetable deposits 



1849.] Gayley, Etiology of Intermittent and Remittent Fevers. 55 



and impurities. This has an accession of brackish water from the oozy 
Lagan, the principal river of the port, at every tide. Notwithstanding the 
emanations and fetid gases from that effervescing fen are constant, they do 
not engender agues." • (Sir J. Murray in Dublin Med. Press, Nov. 1844.) 
Fort Moultrie, at the mouth of Charleston harbour, is another example. 
" Although there is much salt water marsh in the rear of the island on 
which it is situated, no deleterious effects arise." (Medical Statistics of 
U. S. Army.) Similar examples are found in Forts Brady, Howard and 
Winnebago ; while at Forts Niagara, Washington, and Bellona Arsenal, 
where no marshes exist, these fevers are prevalent. 

- Some have dwelt much on the agency of putrefying animal matter in 
producing the poison ; but the argument is more specious than solid. Dr. 
James Johnson, who resided many years in British India, and who de- 
voted much attention to these diseases, in speaking of their causes, says, 
" that during the month of May and beginning of June, when the rivers 
are sunk far within their autumnal boundaries, when the heat is excessive, 
and when the tides are so rapid that the bore, as it is called, rushes up past 
Calcutta, sometimes with the amazing velocity of twenty miles an hour, 
not entirely stopping till it reaches Niaserai, thirty-five miles above the 
capital; then indeed, at low water, each side of the river presents a broad 
shelving slope of mud and mire, covered with vegeto-animai remains in 
all stages of putrefaction and disengaging the most abominable stench, yet 
no ill effects whatever are produced by such exhalations." (Tropical Cli- 
mates, p. 107.) 

In view of all these facts, we think we may safely doubt the tenability 
of the theory of vegetable and vegeto-animai decomposition. On the con- 
trary we see that as a country becomes improved and vegetable production — 
and in consequence vegetable decomposition — is increased, the disease di- 
minishes. 

Let us next examine the theory of Ferguson, viz., that the poison is 
generated in the rapid drying of a porous sandy surface : — or, in other 
words, for producing the miasm it is requisite that there should be a sur- 
face capable of absorbing moisture, and that this surface should be flooded 
and soaked with water and then dried ; and the higher the temperature 
and the quicker the drying process, the more plentiful and virulent is the 
poison that is evolved. 

The distinguished author, from his connection with the medical staff 
of the British army during the Peninsular war, enjoyed an extensive field 
for observation; and his subsequent appointment on the medico-topo- 
graphical survey of the West Indies, during the years 1815, '16, and '17, 
gave him diversified opportunities for adding to, and verifying, the obser- 
vations he had previously made, all of which he sedulously improved, 
and has given us as the result of his labours a number of facts on the 
subject, as valuable as they are interesting. It would make this paper too 
long to insert them here. Neither do we think it necessary for our pre- 
sent purpose. They all go to refute the theory of vegetable decomposi- 
tion. But we humbly think that the one he proposes as a substitute is 
equally objectionable. 

These fevers prevail only in certain seasons, generally in Fall and Spring. 
Is not the soil of places where they do prevail equally as wet during the 
latter part of June and the whole of July — and exposed to suns equally as 
hot, and consequently have the drying process taking place as rapid as 
in August, September, or October,— -April or May ? We think more so. 



56 Gayley, Etiology of Intermittent and Remittent Fevers. [Jan. 



In July, especially, rains are more frequent than in either August or Sep- 
tember. 

The Spring and early part of the Summer of 1847 were unusually dry 
throughout lower Virginia.* The drought prevailed to an alarming extent. 
Vegetation was parched. On the 19th and 20th of June there was a 
copious rain, soaking the ground thoroughly. The following week the 
weather was oppressively hot, — the thermometer at 2| o'clock standing 
from 92° to 94° Fahr. in the shade, except on the 24th, when it stood at 81°. 
Here the ground was thoroughly wet and followed by intense heat, pro- 
ducing, of course, rapid evaporation ; yet not a case of fever followed. 
Whereas, during May, when the whole country around was suffering from 
drought, and the thermometer in only a few instances rose above 80°, chills 
and fevers were very frequent. Other facts might be adduced, but these, 
we think, are sufficient to prove that rapid evaporation from the soil of 
places where these fevers prevail, and the disease, cannot be connected as 
cause and effect. 

The same objection, we think, might be urged against the view that the 
disease is produced by a halitus from the bowels of the earth. What 
makes this halitus innocuous during June and July, and so active in August, 
September, and October ? The fissures, through which it is said to make 
its escape, we have seen as abundant at the one time as at the other. 

These anomalies compel us to doubt the tenability of all the above theo- 
ries. We think they cannot be sustained by an appeal to facts. And the 
more the attention of the profession is directed to the subject, not in one 
place or neighbourhood, but in many dissimilarly situated, the number of 
these, we think, will increase. 

While a student of medicine, I resided between three and four years in a 
miasmatic district. During the first fall of my residence there, intermittent 
and remittent fevers prevailed to an unwonted extent. Very few in the 
neighbourhood escaped. But I observed that the few who did escape were 
among the labourers on the plantation ; and those of them that were taken 
with the fever had it much milder than the household servants. This 
circumstance appeared to me, at first, inexplicable. These persons were 
out before sunrise, and did not return to breakfast until between 7 and 8 
o'clock. They were out regularly, also, until after sun-set. Their work 
lay along the shore of the river, where the miasm is supposed to he most 
abundant. Being out so early, and with empty stomachs, they were cer- 
tainly more exposed to the poison than the household servants, and ought, 
reasoning a priori, to have the disease in a severer form. Yet, taking 
them as a class, comparatively speaking, they escaped. I observed the 
same circumstance the following Spring and Autumn. This led me to doubt 
the correctness of the conclusion that these diseases are produced by a 
specific poison; and to look for their cause in other agencies. 

Among these, as the most important in all natural changes, we first look 
to the effects of temperature. Heat acts as a stimulus to the organic 
functions of the body. The annual changes that take place in the vege- 
table world, and the superior luxuriance of the vegetation of warm cli- 
mates as compared with cold, illustrates this in reference to plants. Simi- 
lar is the effect produced on those functions which man possesses in 
common with plants. The liver and the skin, from the nature of their 
functions, especially are stimulated by heat. The lungs and liver are the 

* The writer was at that time a resident of lower Virginia. 



1849.] Gayley, Etiology of Intermittent and Remittent Fevers. 57 



great decarbonizing- organs of the body, and the activity of their functions 
is always in an inverse ratio. In the lungs, carbon undergoes slow com- 
bustion, accompanied by a disengagement of heat for keeping up the ani- 
mal temperature and is thrown off as carbonic acid. In the liver, it unites 
with hydrogen, and small portions of oxygen and nitrogen, and forms bile. 
In summer, on account of the high temperature of the air, there is less 
demand on' the calorific apparatus within the body ; and the atmosphere, 
on account of its rarity, contains less oxygen in the same volume than in 
winter. These two causes co-operating, will diminish the quantity of 
oxygen taken into the system by respiration, and, in the same proportion, 
the quantity of carbon thrown off as carbonic acid. Hence there will be 
more labour thrown on the liver. For the performance of this, in accord- 
ance with the general law of secretion, increased activity of the circulation 
through the portal system will be required. Of this activity, all the radi- 
cals of the large veins that unite to form the vena portarum must, more or 
less, partake. The circulation must therefore be more active in the digest- 
ive organs during summer than in winter. Its activity is also much 
increased after a meal, because an increased supply of blood is then de- 
manded by the digestive organs. 

The activity of the function of the skin is also much increased during 
summer. The function of the cutaneous surface is twofold, secretory and 
respiratory. As a product of its secretory function, we have perspiration 
and a sebaceous matter for keeping the skin soft and in a proper condition 
for the healthy performance of its functions. Besides this, a large quantity 
of fluid passes off, by simple evaporation, exceeding by far that secreted 
by the sudoriferous glands. [Carpenter, Principles of Physiol., sect. 701.) 
The respiratory function of the skin, though not capable of sustaining life 
in an animal of such active vitality as man, is by no means inconsiderable. 
In some of the lower tribes of animals, indeed, it is a very important part 
of their respiratory process ; and even in some vertebrata the cutaneous 
respiration is capable of supporting life for a considerable time. This is 
especially the case in batrachia, whose skin is soft, thin, and moist. Ex- 
periments which have been made on the human subject leave no room for 
doubt that a similar process is effected through his general surface. 

The skin, therefore, by increased function during summer, keeps the 
temperature of the body down to the proper point by means of its secretory 
power, and the consequent evaporation: while it assists the liver in the 
decarbonization of the blood by means of its respiratory power. The 
manner in which these processes will be performed will depend much on 
the state of the dew-point — -a high one interfering with, and a low one 
favouring, "their proper performance. This brief explanation of the func- 
tions of the liver and skin may help to account for that sympathy that has 
been observed to exist between them.* Heat acts as a stimulus to both. 
Now we know that whenever a stimulus is applied to an organ, one of two 
things must, in general, ensue. If the stimulus applied be constant, and 
the excitement sufficiently kept up for any length of time, serious injury 
is likely to ensue to the organ itself, even so far as alteration of structure. 
But if the application of the stimulus be only temporary, or the force not 
in any great degree, then a reaction follows the excitement, and we have an 
exhausted state of the organ, producing diminution of its function, and 
susceptibility to the action of any depressing agent that may be brought to 
bear on it. 

* Johnson u On Tropical Climates," p. 19, 242. Forrey on Climate, &c. 



60 Gayley, Etiology of Intermittent and Remittent Fevers. [Jan. 

Confirmatory of tins view is the fact that the first attack of yellow fever 
takes place often in the night. {Wood's Practice, p. 297, vol. i.) The 
symptoms of the incipient stage of the severe form of remittent and of 
yellow fever are very much alike : the difference is only in degree, not in 
kind; and this is not greater than the difference in m the intensity of the 
producing causes would lead us to expect. Yellow-fever, then, we think, 
is produced by the same causes as intermittent and remittent, but acting 
with greater intensity. We therefore meet with it only in places where 
these causes exist in a higher degree than where intermittents and remit- 
tents prevail. But on this point we must be more explicit. 

It is generally supposed that countries lying under the equinoctial line, 
or close to it, are subject to the greatest comparative heat, which constantly 
decreases with the increase of distance from that line. This general rule 
must be admitted for the countries that lie between the tropics and the 
poles; but it may be questioned how far it is true of the countries within 
the tropics. A glance at a globe or sphere, shows that the sun, at the end 
of the first month after the equinox, has already advanced 12° of latitude 
towards the tropic, but in the second, it traverses only 8°. At the end of 
the second month it is consequently 20° from the equator. There remains, 
therefore, only 3|° to be traversed in the third month. The sun recedes 
from the tropics in the same way. It passes, the first month, through 3£°, 
the second, through 8°, and the third, through 12° of latitude. Hence, it 
is evident, that at all places between 20° and 23£ of latitude, the solar 
rays during two whole months fall at noon, either perpendicularly or at 
an angle which deviates from a perpendicular only by 3£° at most. If 
we take a place intermediate between 20° and 23|° of latitude, the solar 
rays must fall on it during two whole months either perpendicularly or in 
a direction still less removed from the perpendicular than in the former 
case. On the other hand, when the sun is passing the equator, two places 
on which the vertical rays of the sun fall, on two consecutive days, are 
nearly |° of latitude distant from each other; and a place situated under 
the equator exactly, has only during six days the sun as near its zenith as 
the above mentioned places, near the tropics, have it during two whole 
months. We might, therefore, presume that the summer heat of the latter 
position must be much greater than that of places near the equator. This 
degree of temperature must be still further increased by the greater length 
of the longest days, which, near the tropics, are 13| hours, but at the 
equator, they are always 12 hours. 

This reasoning is borne out by experience. It is much to be regretted 
that so few intertropical meteorological observations have been published, 
and of these we know not how they were made, and how they were af- 
fected by local circumstances. There is, however, a well-established fact 
which clearly shows, that in summer the mean temperature near the tro- 
pics is higher than at the equator. This is the line of perpetual snow, 
which, in the Bolivian Andes, between 14° and 17° south latitude, was 
found, by Mr. Pentland, by a great number of observations, to be at the 
height of 17,000 feet, being 1000 feet higher than it is in Ecuador, under 
the equator. Poeppig, in traversing the Andes near 11° south latitude, 
found that here also the snow line was several hundred feet higher than 
under the equator. The difference would be still greater in the same de- 
gree of north latitude, as all places in the northern hemisphere have a 
Jiigher temperature, as a general rule, than those situated in the southern 
at the same distance from the equator. The countries in which the great- 



1849.] Gayley, Etiology of Intermittent and Remittent Fevers. 61 



est degree of heat may be expected, therefore, are those that lie between 
the 16° or 17° of north latitude and the tropic of Cancer.* 

From the course of the sun, the temperature will diminish more rapidly 
as we go north, than, south from this belt. With this high temperature 
there is also a high dew-point. Humboldt has established the general fact 
(Travels, vol. ii. p. 88), that the humidity of the air approaches saturation 
as we advance to the equator; and that, after getting within the tropics, 
the dew-point rises much more rapidly than the thermometer. The same 
fact has been verified by Forry (on Climate, p. 113), and the tables of M. 
d'Aubuisson. The former has also shown that the atmosphere is more 
humid along the sea-coast, and in the vicinity of tide-water streams, than 
in the elevated regions of the interior, even when the temperature is the 
same (p. 46). In Key West, it is so loaded with humidity that books and 
other articles are soon covered with a greenish mould, and provisions 
spoil in a short time (Ticknor on the Fever of Thomson 1 s Island, in A 7 . 
Jl. Med. and Surg. Journ., 1827). A similar state of the atmosphere 
exists in the West Indies,! and places bordering on the Gulf of Mexico, 
also on the western coast of Africa. Captain Alexander states, that during 
his voyage to the river Gambia, the hygrometer stood at 70°. In the Bight 
of Benin, it stood at 79°. 

Bearing these facts in mind, in connection with the effects of a high 
temperature and dew-point on the system mentioned before, let us examine 
into the locale of yellow-fever. We find it in its most malignant form in 
the West Indies, along the gulf coast of Mexico, as at Tampico, Vera Cruz, 
&c. — all of which lie within the belt defined above as experiencing the 
greatest degrees of heat. We find it also extending south of this, as far as 
5° of north latitude, and north, to New Orleans, Mobile, and Charleston. 
It also prevails as an endemic on the western coast of Africa. But, al- 
though its locale there is without the above limits, yet thermometrical obser- 
vations show a temperature equal, if not greater than that of the West 
Indies.^: It has also been met with in Baltimore, Philadelphia, and New 
York; but only when the temperature of these places was equal to that of 
those visited by it — the average being 80°. 

It has been urged by the advocates of the tellurial origin of yellow fever, 
in support of their views, that the disease is not met with on the eastern 
coast of Africa, or in the East Indies, though in the same latitude with the 
western coast and the West Indies, where the disease is so prevalent. The 
difference in effect, say they, must be owing to some difference in the soil. 
But this argument is more specious than solid. Very little is known of the 
eastern coast of Africa. While the western coast carries on an extensive 

* Maltebrun, for the sake of description, subdivides the torrid zone into three. Of 
these, he says " the equatorial zone, properly so called, is temperate in comparison with 
the zone of the tropic of Cancer, which contains the hottest and least habitable regions of 
the earths Universal Geog., lib. xvii. p. 148. 

f " The moisture of the atmosphere is so great that iron and other metals easily oxy- 
dated, are covered with rust. This humidity continues under a burning sun. The in- 
habitants live (say some writers) in a vapour bath." (Maltebrun's Universal Geog. : lib. 
xciii.) 

J "The sea-coasts' of this region (the tropical region of Western Africa), experience 
the most intense heat that is known in any part of the globe. The cause of this is to 
be found in the east winds, which arrive on these coasts after having swept over the 
burning surface of Africa in all its breadth. * * * Of all the countries of Western 
Africa, the Gold Coast seems to be most subjected to most intense heat. Near the Rio 
Volta, Isert saw the thermometer of Fah. rise to 95° in an apartment, while it was at 
134° in the open air." (Maltebrun's Universal Geog., vol. ii. lib. lxvi. p. 68) 
No. XXXIII.— Jan., 1849. 5 



62 Gayley, Etiology of Intermittent and Remittent Fevers. [Jan. 



trade with European nations in gold-dust, ivory, and slaves, and is also the 
seat of two flourishing colonies ; the eastern, in the same latitude, is seldom 
visited by Europeans. So little, indeed, is known of it, that the existence 
of the Lupata mountains, a chain laid down on most maps as running 
parallel to the coast, still admits of dispute among geographers. The Por- 
tuguese settlement of Mozambique, situated between 10° and 20° south 
latitude, is the only part occupied by Europeans. And, although we have 
no accurate description of its climate, yet we have the general fact stated, 
that it is so unhealthy that " at an average of one hundred soldiers, seven 
only survive a residence of five years." (M Cullocb? & Geograph. Diet., 
art. Mozambique. See also Julia sur V Mr Marecageux, p. 14.) 

But even were the fact established that the disease is not met with on 
the eastern coast of Africa or in the East India Islands, though situated in 
the same latitude with the West Indies, Vera Cruz, &c, it does not militate 
against the theory here advanced. The same latitude does not imply the 
same temperature. Temperature is affected by other agencies, as the 
nature of the soil, the prevailing winds, the quantity of moisture, the elec- 
trical state of the atmosphere, elevation, and the physical character of the 
adjacent countries and seas. The influence of these is very great. Thus 
Mr. Webb found the snow line on the southern declivity of the Himalaya 
mountains, at an elevation of 13,000 feet ; while on the northern declivity, 
though a degree further north, the snow line ascends to 16,000 feet. 
Here they more than neutralize the effects of one degree of latitude. The 
southern declivity rises abruptly from the low plains of the Ganges. The 
northern, though steep, does not descend to a low country, but terminates 
in an immense plain, the surface of which is 10,000 feet above the level 
of the sea. The radiation from this surface is the cause of the difference 
in temperature. {Penny Cycloped., art. Climate.) 

The temperature of the countries of Western Europe differs by 8° or 10° 
from those on the eastern coast of our own country in the same latitude. 
A similar difference is found to exist between our Pacific and Atlantic coasts. 

The discrepancy between parallels of latitude and isothermic lines is 
further shown by the observations of Humboldt. His isothermal line of 
55° 40' Fahr. passes near Philadelphia in latitude 39° 56'; on the Pacific 
coast it is found at Cape Foulweather, a little south of the mouth of the 
Colombia river ; near Pekin in China, latitude 40°, and near Bourdeaux 
in Europe, latitude 45° 46'. The isothermal line of 32° shows a still 
greater difference. It passes between Uleo and Enontakies, Lapland, situ- 
ated respectively in latitude 66° and 68° ; and through Table Bay, Labrador, 
in latitude 54°. These lines were run on the annual temperature. Those 
of seasons differ as much. Thus the isothermal line, (of equal summer 
temperature,) as ascertained from data furnished in the United States Army 
Meteorological Register, passes through Key West, latitude 24° 33', and 
Fort Gibson, latitude 35° 47'. (Forry on Climate.) 

But although they have not the yellow fever in the East Indies, yet they 
have very severe forms of bilious fever — as the jungle-fever and the Bata- 
vian fever; the latter of which it would be very difficult to distinguish from 
yellow fever. The one, as described by Mr. Shields, surgeon in the British 
Navy, and the descriptions of other physicians in the southern part of our 
own country and in the West Indies, when compared, show that they are 
nearly, if not altogether, identical. 

In order to test the accuracy of the opinions I had formed in regard to 
the cause of intermittent fever, I instituted the following experiment. As 



1849.] Gayley, Etiology of Intermittent and Remittent Fevers. 63 



mentioned above, the disease was prevalent every Spring and Fall where 
I lived. About a mile distant there was another plantation where it was 
unknown. I thought that if these views concerning the origin of the 
disease were correct, the daily oscillations of temperature of the two places 
would show a difference corresponding to that exhibited in point of 
health. At the beginning of the month of April I procured two thermo- 
meters exactly alike in appearance, made by the same manufacturer; and 
after trying them in fluids of various degrees of temperature, to make sure 
that they agreed, I left one at the place exempt from the disease, and got a 
member of the family to mark it immediately before sunrise, at twelve 
o'clock M., three P.M., sunset, and at ten o'clock at night. I kept the 
other myself, and marked it at the same hours. 

A record of most of the cases of the disease as they occurred was also 
kept. Owing to the length of the tables thus obtained, and their being 
somewhat imperfect, they are here omitted. As far as they go, however, 
they establish the fact, that the temperature was higher at three o'clock 
P.M., and lower at sunrise and ten o'clock at night, at the place subject to 
the disease, than at the place exempt froui it; and that this difference was 
greater in April, May, and the early part of June, than in the latter part of 
June and July. 

Up to the 20th of April, the thermometer was on one occasion only as 
high as 70°, and only thrice above 60° Fahr. Below 60° the tempera- 
ture is not sufficiently high to lessen materially the demand on the heat- 
generating apparatus within the system. It has still to produce enough of 
heat to keep the temperature of the body 38° above the surrounding atmo- 
sphere. Oxygen, from the part it plays in this process, must still be taken 
into the system in considerable quantities; and the lungs, being the organ 
by which this is effected, continue, comparatively speaking, in reference to 
the liver, the stimulated organ. If a person, under these circumstances, be 
exposed to cold of sufficient intensity to cause internal congestion, the brunt 
of the congestion will fall on some part of the respiratory apparatus, and 
he will have an attack of catarrh, pleurisy, bronchitis, or pneumonia — dis- 
eases quite common at this season. 

From the 20th to the end of April, the thermometer, with one exception, 
was above 70°, and half of the time above 80°. The demand on the heat- 
generating apparatus within the body is evidently much lessened. It has 
now to produce only enough of heat to keep the temperature of the system 
about 20° above the surrounding medium. Less oxygen will, therefore, 
be taken in, and consequently less carbon thrown off as carbonic acid from 
the lungs than in the former case; and there will be more of the decarbon- 
izing labour thrown on the liver. It now becomes stimulated. If, under 
these circumstances, a person be exposed repeatedly to a low temperature, 
as was the case here in the mornings and evenings at the place subject to 
the disease, so as to produce internal congestion, the liver will bear the 
burden of it; and he will have an intermittent or some other disease of 
hepatic origin. Accordingly we have several cases occurring about the last 
of April, and the beginning of May. After the first of June the tempera- 
ture at sunrise was below 60° in a very few instances only. It was at 
these times that the cases of disease met with after this period occurred. 
The range of the thermometer at sunrise and ten o'clock, P. M., during 
June and July, with very few exceptions, showed a temperature not low 
enough to repel the blood from the cutaneous surface on the internal viscera. 
In July it averaged 70°. 



64 



Gayley, Etiology of Intermittent and Remittent Fevers. 



[Jan. 



I was prevented by circumstances from continuing the table through 
August, September, and October, which I very much regret. From the 
prevalence of the disease during these months, a table of their temperature 
would be of great importance. The range of the dew-point ought also to 
have been kept; as the effects of both extremes of temperature are much 
increased by humidity of the atmosphere. But I was prevented from doing 
this on account of the difficulty of obtaining ice. 

An interesting question now presents itself, viz. : how can differences 
of temperature so marked be accounted for in places at such a small dis- 
tance apart? This is readily explained by a little attention to their topo- 
graphy. The place subject to the disease is situated on the east side of, 
and about 150 yards from, the James river, on a hill about 50 feet above 
the level of the stream. Between the base of the hill and the river is a 
level piece of ground, with a sandy alluvial soil, about 60 or 70 yards wide. 
The soil, too, all around the house partakes strongly of the sandy character. 
The banks of the river are precipitous, and the difference between high and 
low water-mark is only about four feet. The place exempt from the dis- 
ease is situate on a higher hill, and three quarters of a mile farther from 
the river. Extending all around between it and the river is a piece of 
woods having a thick undergrowth. The soil is argillaceous. Now we 
know that sand is a good radiator but a bad conductor of heat. During 
the action of the sun's rays the sandy soil at the place subject to the disease 
radiated more caloric than the argillaceous soil at the place exempt from it; 
consequently, the temperature at the former place was the higher during 
the day. But the sandy soil, being a bad conductor, was heated in the day- 
time to a very limited depth only, and after sunset its high radiating power 
brought its temperature down rapidly, so that in a short time it ceased to 
impart caloric to the superincumbent atmosphere. At the same time the 
river continued to absorb heat from the air until both became of the same 
temperature. A low temperature at night was the consequence. On the 
other hand, at the place exempt from the disease, the soil being a better 
conductor became heated during the day to a greater depth ; it therefore 
retained its heat longer, and continued to impart it through the night to the 
air; and the temperature was thus kept higher than at the former place. 

This reasoning derives confirmation from the experiments of Sir Hum- 
phry Davy. He found that when soils are perfectly dry, those that most 
rapidly become heated likewise cool most rapidly. A rich black mould, 
which contained one-fourth vegetable matter, had its temperature raised in 
an hour from 65° to 88° by exposure to sunshine, while a chalk soil was 
heated only to 69°. But the mould, being removed into the shade where 
the temperature was 62°, lost 15°; whereas the chalk, under the same 
circumstances, had lost only 4°. Alluvial and clay soils show similar 
results. 

The experiments of Davy are important in another respect. They ena- 
ble us to account for the prevalence of these diseases in places the soil of 
which is rich in animal and vegetable matter. This fact has been long 
familiar to the profession; and has led to the belief by many, that they are 
caused by a poison generated in the process of vegetable and animal de- 
composition. In the early part of this essay we showed the fallacy of 
such a doctrine. Davy found, that, of the ingredients of soils, animal and 
vegetable matter facilitates most the diminution of temperature; also that 
this property is much increased in all soils by the addition of moisture. A 
clay soil previously dried was artificially heated to 88°, and then exposed 



1849.] Gayley, Etiology of Intermittent and Remittent Fevers. 65 



in a temperature of 57°. In half an hour it had lost only 6°. But an 
equal portion of the same soil, containing moisture, after being heated to 
88°, and then exposed in a temperature of 55°, was found in one quarter 
of an hour to have attained the temperature of the room. Now the soil 
of nearly all places bordering on tide-water streams is rich in these two 
ingredients. A high temperature during the day and a low one at night 
are thus produced. Accompanying this there is also a humid condition of 
the air. " The atmosphere in the neighbourhood of currents of water be- 
comes much more highly charged with aqueous vapour than that of the 
uplands." {Essay on the Influence of Water on Temperature of Soils, 
in Journ. of the Royal Agricultural Soc. of England, by J. Parkes, Esq., 
Chief Engineer to the Soc, 1844.) 

This is verified by the observations of Professor Gardner. He found 
the air, four feet above a sheltered marsh where he made his observations, 
in the height of summer to be so fully charged with the vapour of water 
during the day, as to be within a few degrees of saturation, and surcharged 
with vapour at night. From observations made on an adjoining hill, 700 
feet distant, and elevated 150 feet, the air exhibited a dryness of 12°, 16°, 
and 21°, above the marsh. (Gardner on the " Dew-point," in Am. Journ. 
of Med. Sciences, January, 1846.) The heavy dews of low places prove 
the same fact. This humid condition of the atmosphere increases the 
effects of the high temperature during the day by interfering with the pul- 
monary and cutaneous transpiration, and of the low temperature at night, 
by its being a better conductor of caloric than a dry one. A temperature 
that would be perfectly harmless to vegetation when the air and the plant 
both are dry, will produce frost after a rain and when the air is moist, 
and thus become injurious. Of this fact every farmer is well aware. The 
difference in respect to night temperature between places near, and those 
remote from, streams of water, is further shown by what takes place on the 
occurrence of the late frosts of the Spring, and the early frosts of the Fall. 
Near the streams they are always more severe than at a distance, so that 
plants in the former situations are often killed, while in the latter they 
escape unhurt. Similar is the effect on the animal economy. The severest 
forms of the disease are always met with along the river courses; and in 
southern countries, in such situations, it assumes the type of yellow fever; 
while in the interior it presents the severe remittent form. As we proceed 
north the remittent becomes the prominent type along the bodies of water, 
and gradually becomes lost in the intermittent as we recede from them 
towards the uplands, until at last the disease disappears. 

To the diseases already mentioned as being produced by these causes 
may be added dysentery. Congestions of the hepatic vessels must gorge 
the veins that combine to form the vena portarum. From the enlarged 
spleen produced by intermittents of long standing, we have reason to infer, 
that in slight congestions the splenic vein is the one chiefly involved. 
Whatever gorges the splenic vein must gorge its tributary, the inferior 
mesenteric, which carries the blood from the rectum and the descending 
colon. On this congestion of the mucous membrane inflammation is easily 
lighted up. As in- fevers the congestion may exist in various degrees from 
that which produces the mild intermittent, to the severest forms of yellow; 
so here we have its effects varying from a diarrhcea to the severest forms 
of sporadic cholera. 

The identity of the causes of dysentery and intermittent fever is held 
by most writers on the diseases of tropical climates. They attribute both 



66 Gayley, Etiology of Intermittent and Remittent Fevers. [Jan. 



to malaria. Both diseases prevail at the same season of the year: dys- 
entery among the hills and elevated regions of the interior, and intermittents 
and remittents in the low, level countries along the sea-coast. In many 
places they appear together, the one running into the other. (Forry, p. 
220 ; U. S. Army Med. Stat., p. 27 ; Johnson on Tropical Climates, 
&c. &c.) 

We are now able to explain the occurrence of the disease in the situa- 
tions described by Dr. Ferguson, on which he founded his theory. He 
says : — 

" In the month of June, 1809, our army marched through a singularly dry, 
rocky, and elevated country on the confines of Portugal, the weather having been 
previously so hot for several weeks as to dry up the mountain streams. In some 
of the hilly ravines that had lately been water courses, several of the regiments 
took up their bivouac, for the sake of being near the stagnant pools of water that 
were still left among the rocks. Several were seized with remittents before they 
could leave the bivouac next morning, and that type of fever continued to affect 
the portion of the troops, exclusively, which had so bivouacked for a considerable 
tim©.^ ^ 

"The army advanced to Talavera, through a very dry country, and in the hot- 
test weather fought that celebrated battle which was followed by a retreat into the 
plains of Estremadura, along the course of the Guadiana river, at a time when 
the country was so arid and dry for want of rain, that the Guadiana itself, and all 
the smaller streams had, in fact, ceased to be streams, and were no more than lines 
of detached pools in the courses that had formerly been rivers; and there they suf- 
fered from remittent fevers of such destructive malignity that the enemy, and all 
Europe believed, that the British host was extirpated; and the superstitious natives, 
though sickly themselves, unable to account for disease of such uncommon type 
amongst the strangers, declared they had all been poisoned by eating the mush- 
room (a species of food they hold in abhorrence), which spring up after the first 
Autumnal rains, about the time the epidemic had attained its height. The aggra- 
vated forms of the disease differed little or nothing from the worst yellow fevers 
of the West Indies; and, in all the subsequent campaigns of the Peninsula, the 
same results uniformly followed, whenever, during the hot season, any portion of 
the army was obliged to occupy the arid encampments of the level country." 
{Marsh Poison, p. 5.) 

Similar instances are given by Sir Gilbert Blane. In all these, the 
sandy soil radiated powerfully through the day, making the heat very great; 
but being a bad conductor, it was heated to a depth very little below the 
surface, and radiation ceased soon after sunset. The pools acted like the 
river in the place where the observations given above were taken, and a 
low temperature at night was the consequence. 

But these oscillations of temperature may vary in respect of each other. 
They may be compared to two forces co-operating to produce a given re- 
sult, which may vary in the relative amount of power exerted by each. 
If one does less the other must do more, and vice versa. So here, if the 
heat during the day be great and long continued, and the dew-point high, 
the liver and skin are much weakened by stimulation, and the disease may 
be produced by a change of temperature that would be innocuous if the 
previous stimulation had been less.* On the other hand, if the heat of 
the day has not been great, it will require a greater daily depression to 

* Within the torrid zone, the system becomes so sensible to changes of temperature, 
that a fall of a few degrees of the thermometer is sufficient to cause the inhabitants to 
surfer from cold. Humboldt relates that he and his companions were prevented from 
sleeping by the cold, while the thermometer stood at 71° Fahr. "The humidity which 
modifies the conducting power of air for heat, contributes greatly to these impressions." 



1849.] Gayley, Etiology of Intermittent and Remittent Fevers. 67 



produce the disease. Hence it is that two places may have the same tem- 
perature during the day ; but one, by being near a mill-pond, or a sheet of 
stagnant water under some other name, will have its temperature at night 
brought lower than the other, and its inhabitants will be subject to inter- 
mittents, while those of the other place will be exempt from them. 

This enables us to explain the fact so often met with, that places per- 
fectly healthy, situated near a rapidly running stream, become sickly after 
the stream has been changed into a state of stagnation by having a dam 
thrown across it. The channel of all rapidly running streams is shallow 
and rocky. The rocks become heated through the day and radiate at 
night. The stream being shallow becomes itself heated. Also in a rapidly 
running current there is a great deal of friction. Unless it be an exception 
to everything else in physics, it must generate caloric. These three com- 
bined, must impart considerable heat to the superincumbent air during the 
night. But when the stream becomes stagnant they are all arrested. 

We can also see why the disease is more apt to attack individuals inha- 
biting the first floor of a house than those in the second. The tempera- 
ture at night is always lower in the former than in the latter. Dr. Wells 
found a difference of from 7° to 12° in this respect. The following is 
from a tabular view of his observations on this subject, made on the even- 
ing of the 13th of May, 1813 : — 

6 ft. 45 m. 7h. 7 h. 20 m. 7 h. 40 m. 8 h. 45 m. 
Heat of the air 4 ft. above the grass 60|° 60^° 59° 58° 54° 

" " on the grass plat 53 01 49^ 49 42 

Our own observations found the difference between the upper and lower 
floors of a house two stories high, to vary from 6° to 10°. The effect of 
this difference is much increased by the greater humidity of the air near 
the ground. The walls of rooms on the first floor we have seen covered 
with a heavy deposit of dew, while the rooms above were perfectly dry. 

This enables us, also, to account for the prevalence of the disease in 
the outskirts of large cities, and along the wharves; while in the centre, 
where the streets are paved and thickly built, it is rare. In the former 
situation, from the sparseness of the houses and the absence of the pave- 
ments, there is comparatively little heat imparted to the air by radiation 
after sunset. Also the contiguous river and the pools of stagnant water 
always met with in such situations absorb caloric. A reduction of tem- 
perature is the consequence. Whereas, in the centre of the city, the houses 
and pavements becoming heated during the day, radiate through the night, 
and thus a low temperature is prevented. 

New countries, when first brought under cultivation, are often fertile sources 
of these fevers, but become healthy as the country becomes more improved. 
It may be thus accounted for. In all new countries there is a predominance 
of forests. Indeed, in some places, the settlements, in comparison to them, 
in extent are like islets to the ocean. The surrounding wood interferes 
much with that circulation of air so refreshing and so much needed during 
the day in the summer season. The heat of such situations is therefore 
greater than that of a clear, open country. The air, also, being in a state 
of partial stagnation, becomes more humid. The temperature of the forest, 
at the same time, is kept low by evaporation from the surface of the leaves 
and by the foliage, preventing the calorific rays from reaching the ground. 

(Travels, p. 402.) The same fact is mentioned by Bouguer, in reference to the climate 
of Martinico {Fig. de la Terre), and by Captain Bligh. {Voyage to the South Seas, pp. 
265, 316.) 



68 Gayley, Etiology of Intermittent and Remittent Fevers. [Jan. 



It is a fact well known that snow lies longer in forests than in the open 
country adjacent. It is remarked by Umfreville that, at Hudson's Bay, 
the ground in open plains thaws to the depth of four feet, and in the woods 
to the depth of only two. Moreover, it has been determined by thermo- 
metrical experiments, that the temperature of the forest at the distance of 
twelve inches below the surface of the earth is, compared with an adjacent 
open field, at least 10° lower during the summer months; while no differ- 
ence is observable during the season of winter. After sunset, the surround- 
ing woods act here like the pools and streams of water afore-mentioned. 
This action is assisted by the soil of such places containing much vegetable 
matter, a substance which, Davy has shown, parts with caloric very readily. 
A low temperature at night is thus produced. It is easy to see how re- 
peated attacks on the domain of the forest, and continued cultivation, 
remedy the evil. 

We can also understand how indiscretions in diet, and the depressing 
passions, as fear, grief, &c, aid in producing the disease, "Congestion 
of the portal system is liable to occur when the alimentary canal is dis- 
tended with food." (Carpenter' 's Physiology, p. 543.) The depressing 
and perturbing passions, as fear, grief, anxiety, cause the blood to recede 
from the surface, as is shown by the ashy paleness which they always 
produce. 

Over-indulgence in rich food, containing much fatty matter, likewise 
predisposes to these fevers. Fat contains 80 per cent, of carbon, peas 
and beans 37 per cent., potatoes 12 per cent., and bread 30 per cent. 
Indulgence in rich animal diet in warm weather, when there is so little 
need for the consumption of carbon for keeping up the temperature of the 
body, will have the effect of throwing more labour on the liver. It will be 
stimulated; and, as a consequence, rendered more susceptible to the influ- 
ence of the diurnal changes of temperature. A vegetable diet, on the other 
hand, contains comparatively little carbon, while it is rich in protein, the 
proximate element of all the tissues. In the warm season it will obviously 
be more conducive to health than the other. 

Another interesting fact connected with these diseases is, that they are 
arrested by a heavy frost. A little attention to the effects of frost on the 
air enables us to account for this. The humidity of the atmosphere of 
such situations during the sickly season has been already mentioned. 
This is precipitated by frost. The air then becomes a bad conductor of 
heat and electricity, and has a bracing effect on the system. Fires are 
now made up night and morning. Winter clothing is put on. All these 
cooperating, prevent that internal congestion from which the disease takes 
its origin. A frost not heavy enough to make the inhabitants thus act on the 
defensive, never arrests the disease. All writers on the subject, as well as 
the residents of those districts where it prevails, agree on this point. 

In accordance with the theory here entertained, is the popular prophy- 
lactic measures universally recommended in malarious regions. Popular 
belief is generally founded on correct observation. If a stranger goes into a 
neighbourhood where the disease is prevalent, and asks what measures he 
must take to escape it, he will be told by every one to avoid the hot suns 
by day, and the cool, damp air by night; not to expose himself after sun- 
set, nor before the sun has risen high enough to dispel the chilliness of the 
morning air : or, if he has to expose himself at the dangerous hour, to see to 
it that he is properly protected by additional clothing. All writers on the 
subject recommend the same thing. " A person may, I believe, sleep with 



1849.] Gayley, Etiology of Intermittent and Remittent Fevers. 69 



perfect safety in the centre of the Pontine marshes, by having his room 
well heated by a fire during the night (Sir J. Clarke, Sanative Influence 
of Climate, p. 1 17). The utility of fires has been mentioned also by Pliny, 
who quotes the authority of Empedocles and Hippocrates to the same 
effect. Lancisci points it out at Rome, and Napoleon used them very largely 
and with success when his armies were occupied in the worst districts of 
Italy. It was also resorted to in Africa. " A superintendent engaged in 
directing the cutting of wood erected thirty earthen furnaces on the spot 
where his men were at work, lighting them every day. Before this he 
had always from forty to forty-eight of his workmen sick ; when, in a 
short time they were reduced to twelve, then to four, and finally to one" 
(M'Culloch on Malaria, pp. 285-6). 

I proposed the following two questions to an officer of our navy who 
had spent between two and three years in the Gulf of Mexico. 1. What 
measures were adopted, during your connection with the Gulf squadron, 
to protect the men against fever? 2. Was there any difference in the 
habits, manner of living, &c, between those who had the disease and those 
who had not? If so, state it. 

In reply to the first, he said that orders were given to the men every 
evening at, or immediately before sun-set, to put on their flannel jackets ; 
to the second, that they who neglected to put on their jackets had fever, 
while they who complied with the precautionary orders escaped, generally 
speaking. 

Sir James Clarke, in his work above referred to, in describing the climate 
of the different places, generally has given the daily range of temperature 
and the prevalent diseases. W^herever the former is great, malarious fevers 
are given among the diseases. The reverse is the case where it is small. 
Thus at Pisa, Naples and Rome the daily range is great, and intermittents 
and dysentery are prevalent; while at Madeira and New South Wales, 
where the daily range is small, they are unknown. 

It has often been observed that the crews of vessels lying at some distance 
from a malarious coast, if they sleep on board of the vessel, remain healthy; 
while those of them who may happen to remain over night on shore are 
attacked by the disease. This has been explained by the disciples of the 
miasmatic school by saying that the poison is destroyed by passing over a 
body of water. As to the extent of water necessary for this purpose they 
are not agreed. Sir John Pringle and Sir Gilbert Blane found eight or 
nine hundred yards sufficient in the neighbourhood of Walcheren. The 
former, however, found five miles not enough on another occasion. Lincl 
makes three miles the maximum to which it will travel; while M'Culloch 
thinks it may be carried from Holland to England, or even to Scotland. A 
more philosophical explanation of this fact is furnished by a reference to 
the temperature of the sea and of the land. The diurnal extremes of 
temperature of places bordering on bodies of water has already been men- 
tioned. But the case is different at sea. Humboldt remarks that " in the 
Atlantic between 11° and 17° of latitude, the greatest variations of heat 
rarely exceeded 1.5° or 2° ; and I often observed that from ten in the 
morning to five. in the evening the thermometer did not vary 0.8° of a 
degree. In looking over 1400 thermometrical observations made during 
the voyage of M. Krusentern in the equatorial regions of the South Sea, 
we see that the temperature of the air changed from day to night only 1° 
or 1.3° cent." (Travels, vol. ii. p. 57.) M. Peron says that "every- 
where the sea is colder at noon and warmer at night than the surrounding 
air." (Annates clu Museum, torn. v. pp. 123-148.) This is in harmony 



70 Gayley, Etiology of Intermittent and Remittent Fevers. [Jan. 



also with the experiments of Ellis, Foster, and Irvine (Humboldt, vol. ii. 
p. 71). 

The dew-point over the sea resembles that of high and dry places in 
the interior of the country. This was proved by the observations of Cap- 
tain Sabine during his voyage to the tropics to ascertain the length of 
the second's pendulum. His register commences on the 20th of February, 
1822. During this voyage three measures were made daily, viz. at 8 A. M., 
1 and 6 P. M. The observations were continued on the Gambia and Rio 
Grande rivers. The mean temperature was found to be 70° Fahr. and 
the mean dew-point 57.7° ; hence the average drying power was 12"3°. 

Compare these observations at sea with those made on shore at Sierra 
Leone from the 25th of February to March 22d. These give 78*85° as 
the average mean of the thermometer, and 72.7°, as the average dew-point ; 
so that the average drying power here was but 6.15° or only half of what 
it was on the adjacent seas. 

From this it appears that at sea there is a more equable diurnal tempera- 
ture and a drier atmosphere than there is on shore ; hence one is healthy 
and the other unhealthy. But if a vessel be near the shore, and the wind 
blowing from the land, the persons on board experience more or less of 
the land climate according to their distance from the shore; and with it 
the land diseases. 

That the cause here advocated is of itself capable of producing the dis- 
ease, most writers on the subject admit. " Some have supposed that all 
cases of intermittent have the same origin. Experience, however, is op- 
posed to this opinion. We every now and then meet with instances which 
can by no possibility be traced to miasmata." (Wood's Practice, vol. i. 
p. 239.) 

" We see then this important agent (malaria) greatly varying in force, 
and from standing occasionally the unaided principle, the instar omnium, 
in the production of fever, dwindle away until it can be scarcely distin- 
guished among the auxiliaries. 

" Such being the case, is it not probable that when the latter are numerous 
or powerful, they may in some instances induce the aforesaid disease with- 
out the assistance of marsh exhalations?" (Johnson on Troy. Clim., p. 
122.) " Soldiers and others have been attacked and died of yellow fever 
before they landed in the West Indies or. could be exposed to the influence 
of the land miasmata in any shape." (Ferguson.) 

The experiment of M. Brachet is important and interesting in reference 
to this. Towards the close of October in the year 1822, when the water 
was cold, he bathed at midnight for several successive nights in the river 
Saone. After each bath he betook himself to a warm bed, and in a short 
time was affected with a considerable reaction which terminated in a per- 
spiration. At the end of seven days he omitted the practice, but was, 
nevertheless, affected nightly with a regular intermittent paroxysm. This 
continued for a week, but as he was tolerably well during the day, he de- 
termined not to interfere with it. On the seventh night he was summoned 
before midnight to a woman in labour. The ride to her house heated him, 
and on his arrival there he kept up the heat by placing himself before a 
large fire, and from that time the febrile phenomena ceased. 

This experiment proves the theory almost to a demonstration. 

But while it is acknowledged by those who hold the theory of a teliurial 
origin, that the causes here advocated may and do produce the disease, it 
is likewise admitted that the miasm may lie dormant in the system for 
months, yea for years, if not called out by exposure to extremes of tern- 



1849.] Gayley, Etiology of Intermittent and Remittent Fevers. 71 



perature or by some other of the " auxiliaries." If it may lie dormant for 
years, what is to hinder it from remaining so for life? If then, the causes 
here entertained are sufficient of themselves to produce the disease; and if 
the miasm is not able of itself to produce the same effect, is it logical — is 
it philosophical— to make miasm the cause — the " instar omnium" — of all 
the mischief? 

The periodicity of intermittent fever has given rise to much curious 
theorizing, which we need not here examine. 

In the early part of this essay we have shown that the circulation is 
more active in the portal system in summer than in winter; also that it is 
subject to periodic augmentations every day after each meal. We have 
also shown how a high temperature, long continued, produces debility of 
the liver, and how this debility is increased by the congestions produced 
by repeated exposures to the night air, which, in miasmatic districts, is 
always cool and damp. Under the continued action of these agents this 
debility goes on increasing: the tonicity of the organ decreasing in the 
same proportion, until at last, at one of the periodic determinations of blood 
to the part, the tonicity gives way, and the blood collects in abnormal 
quantities in the portal vessels, and gives us the phenomena of a chill. A 
chill is, therefore, nothing more than the natural periodic determination of 
blood to the part, taking place in excess. The time at which it most gene- 
rally occurs corroborates this view, viz.— in the morning, about noon, or in 
the afternoon. This is the rule: but as the human body is exposed to a 
number of deranging influences, and people differ much in their habits ; so 
we every now and then meet with cases which exhibit a deviation from it. 
We can thus account for the occurrence of the first paroxysm. A recur- 
rence of the chill is prevented by the fever that follows, so long as it lasts. 
But it having passed off, and the atony of the liver and portal vessels re- 
maining, we might expect a return of the ague fit at any of the regular 
periods of determination of blood to the part. Here, however, we find 
another law of the disease which we are unable to explain. We cannot 
tell why a paroxysm occurring in the morning has a disposition to return 
the following morning, and thus give us a quotidian; while one occurring 
about noon is apt to pass over a whole day, and reappear on the third at 
the same hour, giving us a tertian; while one occurring in the afternoon 
will pass over two days, and thus give us a quartan. A solution of this 
must be sought for in the physiological laws of the organ involved. Our 
knowledge of these, however, is very imperfect; and so long as it is so, 
any attempt to explain its pathological laws must end in failure. The one 
is only a modification of the other. 

If the congestion produced by the first paroxysm has been sufficiently 
great to excite inflammation, the febrile condition of system continues; but 
if the inflammation be not extensive, the organ still acts, to a certain extent, 
in accordance with its physiological laws ; and the disease presents remis- 
sions and exacerbations corresponding somewhat to the paroxysm and 
pyrexia of the intermittent. We have thus the phenomena to which the 
term remittent is applied. But if the lesion produced by the congestion 
be very extensive, the derangement of system is so great as to set aside 
entirely the physiological laws of the organ involved; and we have the 
continued form of the fever. 

In conclusion, we give the following as a summary of our views on this 
subject: — 

1. That the lungs and the liver are the great decarbonizing organs of the 



72 Gayley, Etiology of Intermittent and Remittent Fevers. [Jan. 



body ; that, their function being complementary, the activity of that function 
is always in an inverse ratio. 

2. That during winter, the lungs, from the part they perform in the. 
generation of animal heat, are the more active organ. On the other hand, 
in summer, the liver is the more active. 

3. That exposure to a low temperature repels the blood from the surface 
to the internal organs. If this exposure takes place in winter, the lungs 
being then the active organ, the brunt of the congestion falls on some part 
of the respiratory apparatus: hence, we have bronchitis, pleurisy, pneu- 
monia, and catarrh, as the prevailing diseases. 

4. But if this exposure takes place in summer, the liver being then in a 
state of stimulation, the force of the congestion falls on it. It becomes 
deranged, involving all those organs, more or less, whose blood has to pass 
through the liver to reach the heart. Hence, we have bilious affections, 
as intermittents, remittents, dysenteries, &c, as the prevailing diseases. 

5. That the pulmonary diseases of winter and of cold climates, and the 
hepatic diseases of summer and of warm climates, are both produced by 
the same agents acting on the system. The different effects being solely 
owing to the different modifications of the agents, and the different condi- 
tions of the system when exposed to their influence ; and we might with 
as much truth say that malaria was the cause of the one as of the other.* 

Nature is simple in all her operations. It is only in proportion to our 
ignorance that she appears mysterious. The mystery that all admit to 
hang over the origin of these diseases, and the failure that has hitherto 
attended every effort to explain it satisfactorily, we think is solely owing 
to the spirit of inquiry being on the wrong track. The idea of a specific 
poison, first started by Lancisci, has been embraced by most writers on 
the subject ever since : as a consequence, their labours have been expended 
in tracing the origin of a thing, the very existence of which is hypothetical. 

Of the truth of this, the Proteus-like appearance that this agent assumes 
in the hands, or rather the heads of different writers on the subject, is 
prima facie evidence. Thus one describes it as being softened or entirely 
disarmed by passing over 800 yards of water. (Sir G. Blane.) Another 
thinks it can safely perform the voyage from Holland to England, yea, even 
to Scotland, a distance of not less than four hundred miles! (M'Culloch.) 
It cannot ascend to the second story of a house, and yet can seize its vic- 
tim on a mountain side four hundred feet high. (Ferguson.) Stygian-like 
it ascends from the bowels of the earth, and angel-like descends with the 
dews from heaven. Were it delineated with all its eccentricities attached, 
I doubt much if even its most devoted admirers would be pleased with 
the picture. 

Note. — I take this opportunity of expressing my obligations to Dr. Heiskell, acting 
Surgeon General, for copies of the Army Meteorological Register, and of the Army Medical 
Statistics; to Lieut. M. F. Maury, of the National Observatory, and to W. C. Bond, Esq., 
of the Observatory of Harvard University, and to Professor Phillips, of the University 
of North Carolina, for valuable meteorological tables; also to Dr. Geo. Metcalf, of Mendon, 
Mass., ibr meteorological tables, and statistics of disease. Owing to the series of tables 
not being complete, I have postponed drawing on the valuable information they contain, 
for the present. On a future occasion I may resume the subject. 

* Since this essay was prepared, Dr. Hays pointed out to me a paper by Dr. Bell, of 
this city, in which nearly the same views are advocated. I have since read the paper, 
and feel strengthened by the thought, that another, differing much in the manner of in- 
vestigating, should be led to the same result. 



1849.] 



Earle's Cases of Partio- general Paralysis. 



73 



Art. XI. — Cases of Partio- general Paralysis. By Pliny Earle, M. D., 
Physician to the- Bloomingdale Asylum for the Insane, New York. 

The disease illustrated by the following cases is generally known to the 
French as Paralysie Generale. In English, it is designated by two terms, 
General Paralysis and The Paralysis of the Insane. To the former 
appellation there exists the important objection that it is not sufficiently 
distinctive, inasmuch as it is applied to another disease, the ordinary gene- 
ral paralysis, or double hemiplegia. The term Paralysis of the Insane is 
objectionable, because it is a phrase, rather than a name. Again, to some 
physicians it may be unsatisfactory, since they believe that the anormal 
condition which it implies is not peculiar to the insane, but may exist 
without coincident mental aberration. 

The most correct, the most truly scientific basis of medical nomencla- 
ture, is the pathological condition of the system, or of the organs involved. 
But, in the present state of our knowledge, it is impossible to erect a noso- 
logical superstructure upon this foundation. In the particular disease under 
notice, the meninges of the brain are found, upon post-mortem examination, 
in a condition of chronic inflammation. This is especially true of the 
arachnoid membrane, and hence the disease has been called chronic arach- 
noiditis. This term is most evidently inappropriate, from the fact that 
chronic inflammation of the arachnoid very frequently occurs unaccompa- 
nied by paralysis or by mental alienation. Indeed, the existence of these 
latter symptoms, or phenomena, is the exception and not the rule. Soft- 
ening of the brain is also very common in the paralysie generale, yet 
similar reasons to those just alleged would render absurd the attempt to 
designate the disease as cerebral ramollissement. 

The anormal state revealed by necroscopical investigations affording no 
resource for the formation of an exclusive or specific name, it becomes 
necessary to resort to the symptoms by which the disease is manifested. 
The most peculiar and distinctive of these is a partial paralysis of the 
general muscular system. Rarely are the muscles of any organ com- 
pletely deprived of the power of motion in obedience to the will, and when 
they are reduced to that condition, it is as a sequel to a protracted state of 
partial palsy. 

For the reasons thus briefly presented, I believe the term Partio- general 
Paralysis to be the most appropriate for the disease — the most definitive 
of it. That name is consequently adopted in the caption of this article. 

Case I. — H. S. was born in Connecticut. In stature he was tall; his 
hair brown ; temperament bilious-nervous, the nervous greatly predomi- 
nating ; intellect and education good. He was naturally highly irritable 
and easily provoked to anger. He was also constitutionally prone to 



74 



Earle's Cases of Pay 'Ho- general Paralysis. 



[Jan. 



nervous disorders, but was said to have inherited no predisposition to in- 
sanity. He left his native state and commenced business in Georgia, 
where he remained several years. While there he was a " free liver," 
drank wine daily, but, it is said, never to intoxication. 

In the general convulsion of the mercantile community, in 1837, he 
failed in business, and subsequently removed to New York, where he 
established himself as a broker. 

He was married while at the South, had several children, and his wife 
died before he returned to the North. 

For some years he was very eccentric. In 1845 he had an attack of 
paralysis, fell in the street, was taken home and so far recovered that he 
was called well. His mind, however, was enfeebled, his manners more 
eccentric, and he did not recover the entire stability of gait, or perfect 
enunciation of speech, although a casual observer might have perceived 
nothing peculiar in his walk. 

Not long afterwards, he grew rapidly worse ; his mind became more 
feeble, and at length it was necessary to confine him to the house, where 
a man was employed to have the charge of him. 

His bowels were habitually costive ; he was at times noisy, inattentive to 
personal cleanliness, and once or more stripped off all his clothing and ran 
about the house. A simple enema of water was administered daily. 

On the 20th of April, 1847, at the age of 39, he was admitted into the 
Bloomingdale Asylum. His gait was then slightly unstable, with some 
tremor of knees ; pupils contracted ; pulse 80 ; tongue clean, red. 

He was restless, and talked much, but his ideas were few, simple and 
childlike. He willingly consented to remain at the Asylum, was pleased 
with his situation, and continued so during the whole of the time he was 
here, imagining, a large part of the time, that the establishment belonged 
to him. 

During the first two months of his residence with us, he occupied one 
of the best apartments, and did not materially injure or disarrange the fur- 
niture. His appetite was good, he ate voraciously, and imagined his food 
to be of the most luxurious kind. His bowels were rarely, if ever, moved 
without a purgative. A Seidlitz powder was generally sufficient, but he 
took two or three portions of Epsom salts. 

The scope of his ideas was very limited, and having one in his mind, 
he repeated it, in words, for hours in succession. Some of them were as 
follows : " Daughter F. in my mind," " Brandy and water," " I'll live here 
forever and have roast beef for dinner." On the 17th of June, a seton 
which had been put into the back of his neck, immediately after his admis- 
sion, was taken out, as it occasioned but little discharge, and promised no 
benefit. He had now become more excited, noisy, unmanageable, and 
inattentive to his evacuations. He several times stripped off all his cloth- 
ing and refused to be dressed, and at length took up the carpet, put the 
looking-glass and two framed pictures into his bed, laid himself down upon 
them, and broke them. He was then removed to another room — freely 
purged, and kept for a few days upon low diet. He was relieved, but not 
quite so well as when admitted. General sensation was very obtuse. It 
being thought that his taste was nearly or entirely destroyed, a mixture of 
rhubarb and magnesia, in water, was brought to him, and he was asked if 
lie would drink a glass of wine. He drank the mixture and said it was 
good. At this time he began to have exalted ideas, and called himself 
Lord Byron. 



1849.] 



Earle's Cases of Partio- general Paralysis. 



75 



July 12th. Says that James Madison and Lord Baring are his father, 
and that they have purchased a palace for him, in London, at an expense 
of five thousand pounds. 

13th. Says he owns the City Hotel, and that his grandfather is the 
God of Heaven. His feet and legs are oedematous ; general sensation 
appears to be entirely lost; his gait is very unstable; while walking has 
several times fallen to the ground. His speech is much more imperfect 
than when he was admitted. 

15th. Says he is "the God of Heaven and Copenhagen." 

August 1st. Says that his grandfather, Lord Scarborough, is a noble- 
man of the first order. 

Throughout the month of August his bodily condition was somewhat 
better, his gait was firmer, his limbs lost their cedema, and his habits were 
more cleanly. At times he called himself John Jacob Astor, but generally 
"Count Baring of London," and was much irritated if any one addressed 
him by his real name. 

September lSth. For the last six weeks he has been about the house 
daily. He is unsocial, never speaking unless addressed, and even then 
frequently refusing to answer. He generally stands in the corner of the 
room, his face to the wall, his hands crossed upon his breast, muttering 
to himself, and frequently repeating, for hours in succession, some expres- 
sion similar to those before mentioned. While standing, he now leans so 
much to the left, that the right side of his head is perpendicularly above 
the external surface of the left hip. He appears to be failing; is more 
emaciated. His bowels are now habitually so costive that it requires three 
drops of croton oil to move them. 

25th. His body inclines to the right, nearly as much as it did, for 
several days, to the left. Yesterday he fell while walking upon the floor, 
and bruised his face. Sustains himself in the standing posture with 
difficulty ; ideas as extravagant as before ; speech still more imperfect. 

He was now kept in bed a few days, when he rallied, and was again 
about the house. In this way his condition alternated several times. 

December 6th. He is standing against the wall, leaning far to the left 
— silent; all the muscles tremulous. Urged to tell his name, he says 
"Baring." Feet oedematous ; tongue slightly coated, white, pasty. 

From this time he gradually failed, and in the latter part of the month, 
and the beginning of January, 1848, the progress of his disease was rapid. 
His bowels became so costive that it was next to impossible to procure an 
evacuation, by the combined use of cathartics and enemata. He emaciated 
mueh, and became so feeble that, for several days before death, he could 
not rise from the bed. The paralysis was not materially increased. 
On the 27th of January, he died. 

Autopsy, seventeen hours after death. Emaciation extreme. The scalp 
adheres pretty strongly to the cranium, with but little blood in the interme- 
diate vessels. Skull of medium thickness, the tracks of the blood-vessels 
being deeply marked upon its internal surface. Dura mater adherent, in 
places, to the membrane beneath; strongly so to the borders of the hemi- 
spheres beside the median line, where it cannot be detached but by dis- 
section. 

Arachnoid elevated by serum over the sulci. It is thickened over all 
the surface, visible when the brain lies upon its base, semi-opaque in 
many places, and entirely opaque in some. It adheres firmly to the pia- 
mater, which also partakes of its disease. 



76 



Earle's Cases of Partio-general Paralysis. 



[Jan. 



The arteries of the membranes are considerably injected, giving a more 
than naturally rose-coloured aspect to the cerebral surface. 

Nothing peculiar about the cineritious substance. The medullary pre- 
sents some bloody points upon the surface of a section; generally, it is 
nearly of normal consistence, but the fornix and corpus callosum are soft- 
ened. It is also thought that the corpora striata are less firm than in health; 
but if so, the softening is very slight. 

Lateral ventricles partially distended with serum ; velum interpositum 
thickened ; some small hydatids in the choroid plexus. 

Arachnoid on the base of the brain but slightly diseased. There are 
numerous filamentous adhesions between proximate surfaces around the 
pons varolii, as well as in the fourth ventricle, and in the region of the 
fornix. Aggregate of serum in the encephalon, five ounces; cerebellum 
nearly normal. 

Case II. — J. B. M., admitted April 18th, 1846; native and resident of 
North Carolina; planter, aged 45, unmarried. Stature short, hair brown, 
eyes blue; temperament nervous-bilious, with a trace of sanguine. Intel- 
lect mediocre, education liberal, temper naturally irritable and violent. He 
belonged to no religious society; was fond of hunting and horses; but is 
said not to have used intoxicating liquors intemperately, although he has 
been a free liver. Said to have no hereditary predisposition to insanity. 

About two years and three months before admission, he first showed 
symptoms of insanity. Since that he has at times been violent and furious, 
so that it became necessary to confine him in a strait-jacket. 

He once leaped from a second-story window, and threatened to kill him- 
self and others. He has had spasms of the limbs and throat, though not 
during the past year. No medical treatment of importance. 

State on Admission. — Somewhat emaciated, and walks as if he was 
feeble ; pulse 85; pupils unequal, the left the larger; tongue coated yellow; 
mind weak, without the exhibition of any prominent hallucinations. 

\9th. R. — Rhubarb and magnesia. 20th. — Mass. hyd. and aloe pill, j, 
morning and evening. 30th. — Stop pill. R. — Bitter infusion, 3j t. d. 
May 30th. — Stop bitter infusion. 1&. — Ex. conii et fer carb., aa gr. 
x t. d. The conium was increased to gr. xv, and continued until July 
10th. Meanwhile he had taken two cathartics. 

He had now gained some flesh and strength, and his general health ap- 
peared good. The pupils still remained unequal, and he always walked 
as if he were feeble, or as if slip-shod. 

Throughout the fall and winter, he was occasionally subject to a deter- 
mination of blood to the head, with flushing of the face, and loss of appetite. 

These paroxysms were sometimes accompanied by great irritability, 
excitement, loquacity, and imperfect speech ; and, at others, by a state of 
bewilderment and unconsciousness. 

He once attempted, when in his best condition, to write a letter to his 
mother, but did not succeed. There was hesitation in his speech, and 
imperfect pronunciation, throughout the winter of 1847-8. 

March 13th, 1848. During the past month there have been two or 
three times when he could not dress or feed himself, and he now entertains 
exalted ideas of wealth and power; holds his head up; laughs, and, with 
much complacency of manner, says, he is "the richest man in the world: 
has a thousand wives and two thousand horses." 

On being asked his name, says it is J. B. M., and that he holds the 



1849.] 



Earle's Cases of Partio- general Paralysis. 



77 



highest office in the country ; that he is God himself ; that he can walk a 
million of miles in a minute; that he built the Bloomingdale Asylum in 
five minutes, and it did not cost him a cent; but it is so small that he can 
hardly get round in it. 

When standing, he leans to the left ; his gait is feeble and tottering, and 
he falls if there is the slightest unevenness in the ground. Hesitates much 
in speaking, clips many words and utters but few distinctly. Pupils con- 
tracted, that of the right eye the smaller. 

IQth. Much as when last noticed ; sensation on the surface, generally, 
is quite obtuse. At times he strips off all his clothing. 

23 J. Falls frequently when walking, so that he is confined to his room, 
and is mostly in bed. Speaks so imperfectly as not to be understood 
without great difficulty. 

24th. Says he never was so happy as now; has no pain. Taken from 
his bed, he is at first entirely unable to walk without assistance, but, after 
being supported and led a few minutes, he continues to walk alone, although 
with a vacillating and very unstable gait. Whole body partially paralyzed ; 
sensation obtuse. When he attempts to speak, all the muscles of his face 
quiver; tongue very tremulous. Says he has one million, one hundred 
thousand dollars to let. 

April 4th. Falls in attempting to walk. Says he will never eat again 
as long as he lives, and that will be a billion of years. 

17th. Attacked with paralysis last night; lies unconscious; breathing 
somewhat stertorous; extremities warm; flexors of the limbs of the right 
side contracted. 

19th. A little more conscious, but does not speak; right side com- 
pletely paralyzed; the limbs on that side are flexed ; left pupil the largest, 
21st. Cannot speak, but smiles when spoken to. 
25th. Cannot speak or move. 
Died 28th of April, 1848. 

The medical treatment subsequent to the 1st of March, consisted prin- 
cipally of cathartics and stimulating pediluvia. . 

Autopsy, fourteen hours after death. The scalp adheres strongly to the 
cranium, at the median line, along the vertex. Eight ounces of serum were 
discharged when the skull was opened. The cranium adheres to the dura 
mater more strongly than natural. The skull is more than usually thick, 
and the lines of the blood-vessels on the inside are remarkably deep. The 
brain is collapsed and flabby, as if not large enough to fill the cavity. The 
dura mater adheres to the parts beneath it, by bridles and large patches 
which have to be dissected off. These adhesions are principally beside 
the median line, on both hemispheres, and the largest extends two inches 
along the vertex. Here, the arachnoid membrane is perfectly opaque, and 
there are large patches of coagulated lymph, intermingled with white, 
granular bodies. 

The dura mater being removed, the arachnoid appears thickened and 
semi-opaque, on the whole of the superior and lateral surfaces. The 
blood-vessels are congested, but not remarkably so. 

The arachnoid and pia mater adhere to each other in all parts. In re- 
moving the latter, it leaves the convolutions freely in most places, but in 
some, particularly on the superior surface, it takes a portion of cortical 
matter with it. 

The amount of disease, on either side of the median line, is such as to 
make a prominent ridge on each hemisphere. The two hemispheres ad- 
No. XXXIIL— Jan., 1849. 6 



78 



Earle's Cases of Partio- general Paralysis. 



[Jan. 



here strongly to the falx, and anteriorly to each other. The convolutions 
are atrophied. The cineritious matter about of its natural colour; on sec- 
tion, the medullary substance has very few bloody points. The corpus 
callosum is so soft that the weight of the brain, as it lies on the table, tears 
it apart at the posterior border. There are hydatids in the choroid plexus. 
In the middle lobe of the left hemisphere of the brain, there is an apoplec- 
tic foyer, about the size of a New York shilling, or English sixpence, con- 
taining a very black, grumous clot, equal now to about half a fluidrachm. 
This foyer is in the posterior lateral border of the corpus striatum. — Upon 
the whole base of the brain the arachnoid is thickened and translucent, 
with many adhesions between the adjacent parts. 

The cerebellum is thought to be somewhat softened. Its investing 
membrane is slightly thickened. There are many filamentous adhesions 
in the fourth ventricle, and about the fornix. The blood-vessels of the 
brain, both arteries and veins, are thickened and indurated. 

Heart. — In size the heart is apparently natural; and the valves are 
healthy. In the right ventricle there is a firm, light-coloured fibrinous 
coagulum, which extends into the pulmonary arteries, even into branches 
of the third bifurcation. 

The aorta is apparently of its normal dimensions, but upon its internal 
surface there are numerous ossified plaques. They commence immediately 
above the semi-lunar valves, and some are found as far down as the seventh 
costal arteries. Near the valves, one-half of the surface is covered by 
them, and they gradually diminish in size and number beyond that region. 

Case III. — B. H. was a native of Maine, aged 33 years, unmarried, 
tall in stature, hair very dark brown, eyes hazel, temperament nervous- 
bilious, fair intellectual powers, and good common education. 

He had lived an unsettled life, not having steadily pursued any occupa- 
tion for a great length of time, and being subjected to some difficulties on 
account of his pecuniary means. 

Although not entirely abstemious from spirituous liquors, yet he never 
drank to intoxication. 

In 1844, he obtained a sufficiently lucrative place in the city of New 
York, the duties of which he accurately performed, until the latter part of 
November, 1846. In the autumn of the year last mentioned, he be- 
came affianced to a young lady, but afterwards broke the engagement, 
assigning to some of his friends as a reason, that he had become impotent. 
Throughout the autumn some eccentricities of conduct were observed, and 
about the 1st of December, he became decidedly insane, and was taken 
to the Asylum on Blackwell's Island, whence he was transferred to this 
Institution, on the 29th of the same month. It is said that he inherited no 
disposition to insanity. 

State on admission. — His posture is remarkably erect, but his legs totter 
slightly when he walks. He is emaciated and sallow ; and his hands 
tremulous. The pupils are natural; tongue coated; pasty; pulse 102. 
He converses rationally upon ordinary topics which have no relation to 
himself. He says he is a "first rate" singer, and can excel many of those 
who sing at the opera, but, when attempting to perform, utterly fails; says 
that he is a "first rate" physician, that he studied and graduated at Bow- 
doin College, didn't like the business, and went into an apothecary's store, 
thence into a dry-goods store, &c. &c. — Talks much of a precious stone 
which was presented to him. Of this stone he afterwards gave the follow- 
ing account in writing : 



1849.] 



Earle's Cases of Partio- general Paralysis. 



79 



"The Stone." — li In the year 1844, the writer of this being in his office, in the 
Empire City — early one morning, when the birds wild caroled on the spray, there 
came a man, tall in the image of his God he stood, his hair was long and white 
and so his beard, he said he was a man of God and that he wished to preach to 
the sailors upon the wharves on Sunday, but had been prevented; the writer went 
with him to, the Mayor's office, and got permission to speak : he frequently visited 
the writer and gave him council and advice. Many weeks and months had passed 
by; he came to say farewell, put his hand upon my head and blessed me and gave 
me all he had, a small smooth white stone, the Philosopher's Stone, conjuring me 
by all that was sacred and holy to keep it until he died. I have found it in reality 
to be the stone described, containing industry, good luck, wealth, virtue, wisdom, 
prudence, peace, discretion, united with all the beauties of a diadem worn by a 
Christian. The Pilgrim is now dead, the stone I have. You wish for it Doctor 
E . you can have it upon one condition." 

Jan. 3d, 1847. Constantly talking of his wealth and abilities. 

8th. Says he is going to have one of the rooms in the men's depart- 
ment fitted up with great splendour for a library of fifty thousand volumes. 

9th. Says he has an income of one thousand dollars per week — makes 
promises of valuable presents to all around him. 

10th. Is excitable ; easily irritated; was allowed to have his cane until 
he raised it to strike a patient who displeased him. 

15th. Says he has four elegant white horses with grooms, in the city, 
and wishes to have them sent for. 

2'Sd. Wrote the following letter: 

11 My dear Mother and dearest Sister L. 

I sit down to write you after having been to Church, and I am as calm as the last 
ray of summer that shuts the rose — now dearest mother and sister rejoice and re- 
turn thanks to God, the giver of all good and perfect gifts for what 1 am to inform 
you of. — Mother I want you and L — to come to me immediately when you get 
this. On the day after I saw you and L — , to wit, on Saturday, a gentleman from 
New York called upon me; he had been there before and conversed with me, but 
I did not know what he wanted until he came on Saturday; he is one of the most 
wealthy men in the city, one of your customers; although he did not know that I 
knew you, he it seems has heard of me (ah ! I should say that this gentleman is 
worth five millions of dollars) ; now to my business, he has heard of me 1 know 
not how, and of my knowledge of books, and mother I have been employed by 
him to select his library for him. I shall begin as soon as I can. I shall have to 
go to Boston and also to Philadelphia, and then he is going to send me to London 
for selections, and to Paris and Italy and Rome. I shall have a year to make my 
selections, and more time if I want it, and now my dear mother and sister what 
think you my salary is to be % I am almost afraid to tell you for fear that you will 
doubt my word, but what I state is the truth, my salary is to be ten thousand dol- 
lars a year and all expenses paid. I am to select about half a million volumes 
and have them bound. Now mother what think you of your boy and your future 
son-in-law, how is it now sweet bird L — will you not be my wife? 1 think you 
will be equal to Miss P — or she that was Miss L — or any of the ladies in F— ■ 
street, and besides, mother, I have had another offer from M. H. G. — and the Pre- 
sident of the Gas works, and some other gentleman who came here ; they want 
me to take charge of money that will be paid in for erecting a monument for 
Washington ; that, they say, will be worth twenty thousand a year to me or any 
who can get it ; now you will see all about that little philosopher's stone that the 
man of God gave me. Oh let me weep; there's bliss in tears when we who shed 
them only feel some lingering strain of early years effaced by every drop that 
steals. Mother, as soon as I can see you I will make you and L. — God bless 
you, independent, nay rich; you shall go and pay Mr. B. — all of your notes and 
bills, and make all of your poor friends happy. (I must stop again and weep.) 
Tell Mrs. M. — to write to J. — that we shall all, that is you, L. — and myself and 
Mrs. M. — be in Europe as soon as spring time, — next week, or after you 



80 



Earle's Cases of Partio- general Paralysis. 



[Jan. 



settle your business, we must go to Boston, and then to Washington and Philadel- 
phia and select books and prints. Oh we will have fine times, but keep this to 
yourself and L. — at present, until I see you (don't even say aught to Dr. E. — ) 
I shall be all quiet until I counsel with you and L. — and then as calm almost as the 
love of God. Come up immediately this morning." 

27th. The following is extracted from an autobiography which he wrote. 

" Finally, after being everything, he came to the city of New York, six years 
since, and a great trait in his character is that he has continued to improve and 
practice upon all his former studies and researches, and in addition to them he has 
taken up and read the laws of all the states in New England and New York, al- 
though he has not been admitted or has he made an application, yet he is versed 
in theology more than any person we ever met with^ and we think if he was 
willing he could decide any demonstration of anatomy, and we are really afraid 
when he talks about chemistry and bottling heaven's lightning. He understands 
the common and written law better we think than any man now living, both here 
and in England. There is no calculating the amount of his reading, and he never 
read a line but what he remembered it. He can repeat Pope and Cowper like 
ABC, and heaven only knows the amount of languages he can speak. And 
what is more beautiful he is one of the finest, most chaste and beautiful writers 
both of prose and poetry that now lives, and we think no one can beat him since 
Pope, — if he will do his best, his language is so beautiful and fine. But he will 
not indulge in writing for some reason known only to himself. And then again 
he is one of the most beautiful speakers and powerful orators that ever lived; we 
never heard Demosthenes and Cicero, but we think no person can begin with him. 
When he speaks his supernatural voice sounds in your ears, and along your ar- 
teries — your soul is on fire. Speaking of poetry, he makes all weep — and speak- 
ing of God and nature scarcely any person can listen, they will be so overpowered 
with their feelings. His voice is beautiful, not husky or shamed, and his words 
flow like the pure limpid stream. We hope that we may hear him in some public 
place, but we are informed that he has been elected to two very lucrative offices; 
the salaries amount to thirty thousand, and we think he will not trouble himself 
very much except to speak upon his famous topic, — Democracy." 

Feb. 20th. He talks almost incessantly, if he can obtain listeners; al- 
ways has a more remarkable story to tell than any other person, and, 
although relating them as facts, it is evident that they are embellished by 
his imagination to a degree corresponding with his ideas of his own wealth 
and capacity. 

March 8th. Exerts more self-control, but his ideas are as extravagant 
as before. 

April 5th. Says he is the greatest of all anatomists, owns the largest 
library in the world, has many millions of golden half-eagles at his com- 
mand, speaks numerous languages, is master of more than three hundred 
dialects, and is going to sing at the Park Theatre for a thousand dollars a 
night. 

19th. Says that a large legacy has been bequeathed to him in England, 
and he is going to take possession of it. Offers his attendant a thousand 
dollars a year, and an introduction to the Queen, if he will accompany him. 

May 1st. Says he is to be elected Mayor of New York, and that se- 
veral aldermen have been up to see if he will accept the office. He intends 
to establish a bank in Wall Street, with a capital of many millions, so as 
to completely monopolize the money market. 

20th. Says he is going to write the history of Rome. 

June iOth. Says that after three months' deliberation he has completed 
a plan for converting the Bloomingdale Asylum into an academy of arts 
and sciences, with teachers of all branches of learning. The matriculation 
fee is to be one thousand dollars, and students are to live on gruel in order 



1849.] Earle's Cases of Par Ho -general Paralysis. 



31 



that their minds may be clear. In honour of the completion of the plan 
he is going to have the city illuminated to night, and twelve millions of 
pounds of powder will be burnt. 

24th. Says he will make a prescription for Mr. T., one of the other 
patients, and if it does not cure him he will forfeit fifty millions of dollars. 

July 12th. Says that Polk is going to send him minister to Russia. 
His speech is somewhat affected, and the muscles of the tongue and mouth 
have not their natural stability. 

But a very small portion of his extravagant fancies have been recorded. 
Daily and almost hourly he has some new idea relative to his own aggran- 
dizement, or some novel scheme for the accomplishment of an object re- 
quiring, even if possible to be accomplished, either unlimited pecuniary 
resources, or great intellectual ability. His memory appears to be good in 
relation to things which occurred in his past life, but not of recent events. 

Oct. 28th. Hands and feet somewhat cedematous. 

Nov. 12th. Pupils considerably contracted, equal; tongue very slightly 
coated, moist, exceedingly tremulous ; hands tremulous ; lips, when he reads, 
tremble. He drops the last syllable of some words. Gait unstable, and 
posture less erect than formerly. 

Throughout the fall and winter his appetite and digestion were good, 
and he was heavier than before, though he appeared to be somewhat bloated. 
His strength was diminished and he was unable to bear much exercise. 
His posture became more and more stooping, and his gait less and less 
stable. He was much less irritable, talked comparatively little, and rarely 
alluded to any of his exalted ideas. 

During the first twenty days of March he frequently fell while walking, 
upon the floor, and without encountering any obstacle. 

March 24th. Unable to stand ; face and hands bloated, pupils contracted, 
unequal, the right the smallest. All his limbs partially paralyzed. When 
he protrudes his tongue all the muscles of the cheek, as well as the tongue 
itself, tremble spasmodically. Sensation appears perfect. For a few days 
past he has talked more of imaginary wealth. 

April 4th. Having been freely purged, he has rallied so that he walks 
pretty well. Pupils unequal, left much the larger; says he is married and 
has a child nine months old. 

10th. Walks about the hall ; lame in left leg; appears to be looking after 
something, goes where he thinks it is — then forgets what he is after. 

llth. Had convulsions about noon, which lasted from two to three 
hours, with excessive spasmodic action of the muscles, particularly of the 
left side. 

12th. More comfortable, left side completely paralyzed. He has con- 
sciousness, but his mind is very feeble. 

13th, Thinks himself perfectly well; wishes to have the doctor called, 
in order to run a race; says he can run a mile in three minutes. 

15th. Can move the limbs of the left side a very little. There is par- 
tial paralysis of the right side, and paralysis of the bladder. Pupils still 
unequal; bowels very costive, and moved only by enormous portions of 
medicine. 

17th. Emaciates, though his appetite is good. He speaks and swallows 
with difficulty. The limbs of the left side remain flexed, the flexors still 
having some power. He recognizes his acquaintance. 

21st. Failing rapidly ; extremities cold, purple, eyes sunken ; he appears 
conscious, but cannot speak. 



82 



Earle's Cases of Partio- general Paralysis. 



[Jan. 



22d. Died at five o'clock P. M. 

His medical treatment while in the asylum, consisted of alteratives and 
tonics, with purgatives when necessary. 

Autopsy, twenty-four hours after death. — Cranium pretty strongly ad- 
herent to the subjacent membrane. Glands of Pacchioni numerous, some 
of them projecting through the dura mater. The dura mater adheres by 
filamentous attachments, in several places, to the membranes beneath it, and 
so closely for several inches along the superior border of each hemisphere, 
as to be removed only by dissection. The arachnoid is thickened, whitish, 
and semi-opaque, generally upon all the superior and lateral surfaces, and 
in spots perfectly opaque. It is elevated over the sulci by transparent 
serum. The blood-vessels rather more than normally injected, but not 
highly so. The pia mater appears somewhat thickened, and adheres, in 
places, to the cineritious substance. The brain, as a mass, is softer or 
more flaccid than is natural in health. The cortical substance is not dis- 
coloured, nor does it appear to be softened. Upon section, the medullary 
matter is evidently less consistent than in health, and presents many bloody 
points. The greatest amount of softening is in the corpora striata and the 
parts exteriorly or laterally adjacent to them. The softening is farther 
advanced in the right hemisphere than in the left. 

The proximate surfaces of all parts of the brain, between the hemispheres, 
in the fourth ventricle, anteriorly to the pons varolii — and internally, in 
the neighbourhood of the fornix, are connected by filamentous bridles. On 
the base of the brain the arachnoid is but little thickened. Some hydatids 
in the choroid plexus. Lateral ventricles distended with serum — the whole 
quantity of which from between the membranes, in the ventricles, and at 
the base of the brain, is eight ounces. 

Cerebellum thought to be anormally soft. Its investing arachnoid 
slightly thickened in some places. 

Case IV. — J. B., a seaman, aged 52 years, native of Germany, and for 
some time resident at the institution on Staten Island called " The Sailors' 
Snug Harbor," was admitted into the Bloomingdale Asylum, Feb. 21st, 
1848. But little information of his previous history could be obtained. 
It was said that his mental disorder had not been noticed but about two 
months. 

When admitted he was excited and talkative, his language rapid, in- 
coherent, confused and occasionally interlarded with the word Dodo, which 
he appeared to apply to himself. 

Tongue slightly coated, bowels costive, pupils contracted. 

After catharsis with castor oil he was put upon the use of small doses 
of antimony and digitalis, which were continued until the 6th of March, 
when he had become quiet, less talkative and comparatively rational. 
As, however, he spoke English but imperfectly, it was difficult to ascertain 
the precise condition of his mental faculties. 

It became evident that the term Dodo, which he almost invariably em- 
ployed when speaking of himself, was considered by him as indicative of 
power, and he sometimes used it with such gesticulations as implied su- 
preme authority. 

After the 6th of March his appetite and general health were pretty good, 
and remained so until the 15th of May, when he had an epileptiform fit, 
followed by stupidity, torpor, if not partial paralysis of the muscular 
system, and almost entire obscuration of the mental faculties. He had 



1849.] Earle's Cases of Partio- general Paralysis. 83 



stimulating pediluvia, low diet, and was freely purged for several days in 
succession. He improved so that he left his bed, but could scarcely walk 
without assistance, partly from debility ; but chiefly from inability to use 
his muscles. 

Vegetable tonics were now administered ; but without apparent benefit. 
On the 3d of June there was hemiplegia of the right side, but without en- 
tire loss of muscular power. 

June 19th. Mind perfectly imbecile ; right side as stated at last date. 
He can neither feed nor dress himself. Evacuations passed in bed. 

21st. Had another "fit." Complete hemiplegia of right side. Left 
side partially paralyzed ; the flexors having more power than the extensors. 
Pupils unequal, left the largest. 

These symptoms continued, and the last week of his life was a mere 
automatic existence. Died July 3d, 1848. 

Autopsy, thirty hours after death. Head. Cranium of medium thick- 
ness and pretty strongly adherent to the membrane beneath. Around the 
vertex, there are several small lacunas in the dura mater attributed to the 
glands of Pacchioni. 

The dura mater is attached to the subjacent membranes of both hemi- 
spheres, upon the anterior surface of the cerebrum, and for four inches 
along the vertex, beside the longitudinal sinus. These latter adhesions are 
so close and firm that dissection is necessary for the separation of the 
membranes. 

No adhesions to the falx. The parietes of the larger blood-vessels are 
thickened and semi-cartilaginous. 

The arachnoid is elevated over the sulci by effused serum ; it is thick- 
ened and semi-opaque throughout the whole of the surface exposed to 
view as the brain lies upon its base, excepting alone such spots as are per- 
fectly opaque. It is intimately adherent to the pia mater at their natural 
points of contact. 

The pia mater adheres to the cerebral mass, though not so strongly as 
upon removal, to take portions with it. In the anfractuosities it is thickened 
and its vessels much congested. 

The brain, before being cut, appears remarkably soft, lax, flabby. The 
cineritious matter is evidently softened ; but with an exception to be noticed, 
retains its normal colour. 

Afler making a section of the superior portion of the brain, the surface 
of the medullary substance becomes mottled with bloody points; blood as 
usual, oozing from the cut vessels. 

In the middle lobe of the right hemisphere, anteriorly and laterally to 
the posterior cornu of the lateral ventricle, there is an abscess containing a 
small quantity of puriform matter. The surrounding substance is degene- 
rated. All the medulla of this hemisphere is much softer than natural, in 
health. 

In the middle lobe, and posterior half of the anterior lobe of the left 
hemisphere, the medulla is much degenerated, of a light iron gray colour; 
its tenacity and fibrous structure entirely lost, and its consistence that of 
thick cream. This degeneration involves the corpus striatum and the optic 
thalamus. The adjacent cortical substance is soft and of a greenish yellow 
hue. 

The corpus callosum, fornix and tubercular quadrigemina are all 
softened. 

The lateral ventricles are partially distended with limpid serum, of 
which the aggregate, in the encephalic cavity, is five ounces. 



84 Earle's Cases of Partio- general Paralysis. [Jan. 



The velum interpositum is thickened, congested and adherent by fila- 
mentous attachments to the surrounding organs. 

The choroid plexus contains many hydatids, one of which is as large 
as a small bean. The pineal gland contains seven pieces of sabulous 
matter, the largest being of the size of a pin's head. 

Upon the base of the brain the membranes are but slightly thickened, 
and their transparency partially impaired. 

There are filamentous adhesions between neighbouring surfaces around 
the pons Varolii and corpora albicantia, and also in the fourth ventricle. 

The pons Varolii and the medulla oblongata are soft and pulpy. 

The arachnoid of the cerebellum is slightly thickened and somewhat of 
a milky or opaline hue. The organ itself thought to be rather softer than 
in its healthy state. 

Thorax. — Lungs partially congested, and their colour unusually dark 
with carbon. 

Heart large; both ventricles distended with partially coagulated blood ; 
the substance of their parietes pretty easily broken down between the 
thumb and finger. 

The valves of the right side are in their normal condition. 

Along the line of union, between the auricle and ventricle of the left 
side, and in the root of the smaller segment of the mitral valve, there is a 
plaque of bone one inch long and one-eighth of an inch wide. Another 
firm spicula, three-quarters of an inch long, lies nearly perpendicularly 
across the line of origin of the larger segment of the mitral valve, and the 
corresponding semilunar valve of the aorta. Two-thirds of its length are 
in the mitral valve, which it retains partially extended or closed ; the other 
third passes through a small segment of the semilunar valve and terminates 
near the attachment of its loose edge with the aorta. 

Springing from very near the centre of the base of the same semilunar 
valve, there is another spicula which passes directly across it, terminating 
near the middle of its loose border. This is so hard and so firmly fixed 
at its base that it keeps the valve in a position about two-thirds extended 
or closed. 

The aorta is enlarged to apparently twice its normal capacity, through- 
out the space of one foot from the heart. Its parietes are much thickened, 
semi-cartilaginous and rugose. The lining membrane is deeply injected 
and in some patches intensely red. In the space between the heart and 
the summit of the arch there are many ossified plaques. One of these 
surrounds the origin of the left carotid artery, the opening into which it 
has diminished to the diameter of one line. The opening of the right 
carotid is correspondingly enlarged. 

Case V. — J. H. was born in Pennsylvania, but removed thence to the 
city of New York. His stature was medium, hair black, eyes chestnut, 
and temperament nervous-bilious, with a trace of sanguine. 

His intellectual powers were sufficiently strong, and he had a fair, com- 
mon education. He was constitutionally irritable, but, according to the 
testimony of his friends, he inherited no predisposition to mental disorder. 
He married in 1827, and about nine years afterwards, at the age of thirty- 
five years, had an attack of insanity, which was attributed to grief from 
the death of an only child. The mental alienation did not continue long, 
and his friends say that his recovery was perfect. 

In the course of his life he had been engaged in divers kinds of business, 
and at length obtained a situation as an officer of the police. 



1849.] Earle's Cases of Partio- general Paralysis. 



85 



Here, it is said that an undue portion of his time and exertions was 
devoted to the duties of the place. For two or three years his health 
gradually failed; he .grew increasingly irritable and easily provoked to 
paroxysms of anger. About the 1st of September, 1846, he became de- 
cidedly insane. He was highly excited, slept very little, talked almost 
incessantly, having various delusions, some of them of a religious character. 

At length his violence increased so that it became necessary to confine 
his limbs, and, on the 28th of that month, at the age of 45 years, he was 
received into the Bloomingdale Asylum. 

Condition on admission. — He is highly excited, restless, talkative and 
incoherent. He hesitates in speaking, and pronounces some words imper- 
fectly. There is a tremulous instability of the limbs, as if he were highly 
nervous or agitated. Veins of the face and head turgid ; pupils unequal, 
the right being the larger ; tongue coated, white, pasty. 

When he was informed that he must remain in the asylum he became 
furious, broke windows, and threatened to prosecute for false imprisonment. 

After a cathartic of jalap and cream of tartar, he was put upon the use 
of blue mass gr. ij t. d. and sedative doses of antimony and digitalis. The 
former was continued until Oct. 2d and the latter until Oct. 3d, when it 
was substituted by a mixture of camphor, hyoscyamus and assafcetida. 

Oct. 6th. Excitement continues, although mitigated. He talks much, 
ideas of wealth and power predominating. Turgescence of the vessels of 
the head. R. — Cut cups ^x ad nucham. 

7th. Bowels habitually costive. R. — Compound cathartic pill j t. d. 
On the 11th the mixture of camphor, &c, was stopped, and the antimony 
and digitalis resumed and continued until Nov. 7th. He had now become 
much more quiet. 

Nov. 14th. Again excited, tongue furred, white, pasty. R. — Cal. gr. 
x et jal. gr. vj. 

ISth. Tongue continues pasty. R. — Mass ex hydrarg. gr. ss t. d. 
Dec. 1st. Condition of tongue somewhat improved, bowels regular. 
Stop blue mass. 

He says he has assets of over two and a half millions of property of his 
own, and can raise two hundred thousand dollars at two hours' notice ; 
that his wife is also worth two and a half millions, although when he mar- 
ried her he did not know she was wealthy. He says he can lift more 
with his right arm than any other two men ; and if any man can beat him 
at running, he must run like the devil. Tongue spasmodically tremulous, 
and when he hesitates, in speaking, the effort to continue causes spasmodic 
action of the muscles of the mouth. Being somewhat excited, he now, 
for two days, took sulph. morph. gr. | t. d. It contracted the pupils, and 
increased the disposition of turgescence of the veins of the head, and was 
consequently stopped. 

17th. He yesterday wrote the following letter: 

"New York, December 16th. 

Bloomingdale Asylum Mr. M***** Dear Sir will you please to call on J. H*** 
I want to loan the money of you which you have to let and I will give mortgage on 
twenty Churches J. H**=* 

Mr. M***** you will please call on J. H**** at the Bloomingdale Asylum. 
Mr. S* # *** you will please call at the Lunatick Asylum. J. H*** the anerable 
Mayor will please to Call on J H*** at the Lunatick Asylum, the sculptor will 
please to call on J. H*** at the Bloomingdale Asylum, the Steamboat proprietors 
will call on J. H*** at the Lunatic Asylum. Catharine A. H*** will Call on her 
Dear Husband at the Bloomia Assilum Ad see her Dear Husband Bring all of 
your furniture an every Body around J. H**=* 7; 



86 



Earle's Cases of Pan 'tio- general Paralysis. 



[Jan. 



And, soon after, the following: 

"New York Deer 23. 
Mr. H*** # Bloomingdale Asylum 

Dear Sir you will please to forward all your best horses and call on 
Mr. M** # ** and forward all his best Cadges, and call on the gentlemen as fol- 
lows — Call on D. V*** 41 C — Street tell him to call on me on the Master of 
Chancery B** ## * auctioneer tell him to call on me with maps of property he has 
for sale as I am Perfectly Prepared to Purchase all the property Call at 65 W*** 
Street, Bring H*** and 31 with his Juelry Call on the Gentlemen who have the 
Albany Steamboats for sale — Let them come up and send me all the mahogany 
and fine wood and marble — Call on the Comonality and Margarality bring them 
up send me the wood and marble first, Send me all the best clothing you can 
find in the city and send me all the working Classes and poor Clas in ihe City 
immediately — Go to the Wine Merchants and Jewelors with their Juelry to Gether 
with the contents of S* # ** # *'s Store. No more at present 

I remain Yours Respectfully. J**^** H**^ 
N. Call on my wife at 102 M*** immediately all our family & Bring her and 
Friends. — Mr. f**** will Please bring his family & all his liquors and all the 
Pennoes that are Ready in his Neighborhood as I will Purchase all the have & 
have all the Mahogany Lord ve 5 and send the same. C**^ # ** D*^** will 
please to bring all his Goods and family to the Asylum Dout forget Mr. D****^ 
or family & his men & all his goods my love this concludes. 

I have the trinity by the Hee — I want stationary and all kinds of goods & want 
all the plants you can bring. Dont for Mr. C********* and the Baker in H # ** # * 
Street & L****** & family Call 123 M*** Street there is a Jerman woman the 
her husband Mr. U****** Bring her and mister S******* with his band — to 
Catharine A H*** m*** 102/*' 



" Mrs. H* # * Dear Wife this is my last letter you will receive you will therefore 
pay particular attention to ihe words to what it contains I am this moment worth 
millions of money and cash and property you will therefore Go to Mr. S****** 
with Mr. Mc C**** and buy the Best Goods he has in the store and give him my 
note payable on Demand — I am here four months Living on two shillings worth 
per day and Sleeping on Straw in the worst place in the whole concern you will 
please to send word on Mr. C*** # ***** and tell him bring me all the contents of 
his store he in P**** Street and one am Silver Smiih in Grand and tell to come 
with his family and all his good and bring the portrait painter an Call on S and 
D#*#*« ail( j bring them and all their Goods Call on the person that ad- 

vertises mesmerism machines and Galvanism machines and tell to forward me 
one of each he advertises in the paper. 

No more at present 
But remain your affectionate 
Husband Joseph 

" I ivant you to send me Billiard tables of B******* Mrs. W*^* will tell Mr. 
B###««# to Bring all his furniture & his family together with Mrs. P******** 
family. Mr. E^*** will please forward his Cargo as I now go to Building. I 
will build over this ground with Mahogany & Rose wood this and raise one gar- 
den on top of the other Higer than the Catskill mountain. I will go with my 
friend there shall be buildings of Gold and Preshus stones, my Gardens Deer 
forrests fruit of every Description and those houses shall go up this afternoon 

No more at present 

" fifty storys High seven three hundred feet each way take the inside out wall 
take the wall and saw the stone 3 story down and seven rooms across the to Sing 
Sing and build Pallace Around them mountains of Gold and precious stones nine 
thousand miles high start for Mexico and kill off and send to this country and put 
them in Museum this evening and Return tomorrow and show y same & Good 
sleighing this night with the Ladies and patients. By getting the Battering ma- 
chine up we will send our Steamboats on with our Rail Road off and Return with 
all the welth of that Cuntry." 

J. H*** 



1849.] Earle's Cases of Partio- general Paralysis. 87 

Dec. llth. — Says he owns all Trinity Church property, and is going 
to enlarge this institution so as to accommodate all the inhabitants of New 
York city, at five dollars each per week. 

26th. — Says he is going to build over all the land of this institution ; and 
as far down as Harlaem with a solid block of buildings from twenty to 
thirty stories high, the material to be rose- wood and marble. 

Being requested to put his plans upon paper, he wrote the following: — 

u I mean to commence building next week on this ground with Rose wood from 
the halam River to making a canal at manhattan ville of 100 ft. wid and Build 
100 stories high which I can do | Day have glass stained windows. Decorating 
with flowers and fruit trees every two story hig. 1 will get the finest of furniture 
in the City Git the birds from the Have all the Good in Store on this Premises 
have museum — theatre manager and all the piannas and organ music in the City 
I will have all watches and in the City and Before new year Go and conquer 
Mexico and bring all their good Gold and silve and wares &o, at catskil I will 
Buld a Pallace of Gold twice the height of the mountain. — I will level the whole 
w r orld and make peace and liberty throuoig the world to the Glory of God the 
father Son and Holy Gost there shall be nothing but Hallalugah to God the father." 

Notwithstanding these extravagant notions, he was about the house and 
comparatively quiet; his memory was pretty good, and when his friends 
saw him he conversed with them, rationally, upon topics unconnected with 
his hallucinations. He now took the extract of conium, commencing with 
gr. x t. d., afterwards raised to gr. xx, and continued until the J 6th of 
February, 1847. 

In the early part of January he said he was a candidate for the next 
presidency, and he knew that he should obtain the office. About the same 
time he requested one of the attendants to write out his plans, and dictated 
the following : — 

"A canal is to commence at Hurlgate, and extend to the North Pole ; and pass 
directly in front of this Asylum. All the waters in the world are to pass into it. 
All the commerce is to be carried through it by steamboats to be described here- 
after. The canal is to be four hundred feet wide, and twenty feet deep. The 
sides are to be laid with polished marble, and the bottom with free-stone taken 
from the Asylum building. The waters will have the sweetest perfumes, giving 
forth their odours only while the ladies promenade on its banks. All the fish and 
everything that swims are to be gathered into these waters; but they will not hurt 
each other, owing to the fragrance of the waters. This seems to have an effect 
upon them similar to that of exhilarating gas upon man, only it continues as long 
as they remain in it. The brain is so stimulated or exhilarated by it, that they 
grow from its pleasure; in fact, nothing could be more nourishing. Young fish 
are but a day in maturing. They can be taken very easily, being almost in a 
state of stupor, and their flesh is far more delicious than that of those in common 
waters. 

,£ The Asylum building is to.be taken down, and a new one erected. The iron 
sashes are to be carried to the City, and made into printing presses to be in readi- 
ness for the new house, which is to be built of black marble, nine thousand and 
fifty stories high. This will bring it within fifty miles of heaven. Above this 
house, in the fifty miles mentioned, every twenty-five feet is to be a garden; this 
will make it high enough for any ornamental tree. In each of these gardens there 
is to be a spring, and the water is to have a very pleasant taste. They will all 
flow into one and form a fountain whose jet will rise many hundred feet. The 
springs are to be formed by all the pleasant waters of the world coming together, 
thus producing a most delicious beverage possessing medicinal powers: capable 
of curing any disease but old age, which he does not wish to cure, as the world 
would become too populous. The different kinds of shrubbery are to be gathered 
from the ends of the earthy and arranged around the fountain according to their 
beauty, 



88 



Earle's Cases of Partio- general Paralysis. 



[Jan. 



"The new house will accommodate billions of people. All the poor of Europe 
are to be brought over to day and put into it, that they may be ready to go to a 
ball which he is to give to-night at Catskill. From the sale of the tickets he ex- 
pects to make enough to pay for the house and furniture. These poor people are 
to be brought over by balloons, made so large that they can attach them to the 
houses, and bring them safe over with the people still in them. 

" To-morrow we are to take five hundred thousand men to Mexico, on a railroad 
made of gold. We are to be armed with fifteen-barreled pistols, loaded with 
gun-cotton. We are to conquer all Mexico, annex it to the United States, esta- 
blish a free government, and return before to-morrow evening, as he then expects 
all the distinguished men of the country to be here to congratulate him upon his 
success. 

" We have a population of thirteen to a square mile : some states have only one : 
but when he gets the land covered with buildings made of rose-wood, golden floors, 
and everything to correspond ; with bedsteads of red cedar, so that there will be 
no bed-bugs, the population will be very dense. The bed-rooms are to be 
elegantly furnished. Museums are to be established, and into them are to be 
gathered specimens of everything upon the face of the earth. Theatres are to be 
constructed in the most costly style. The birds are to be taught to sing by means 
of the hand-organ. The poor are to work one hour after each meal, to give them 
exercise. The furniture of the present asylum is to be taken to the city and sold 
at auction. A painter is to be brought from France to-day, and all the painting 
of the new house is to be done by him to-morrow. The patients are to be cured 
by galvanism. All the land in this country is to be divided into farms of fifty 
acres each. We need not go out of the state of New York for any minerals, as 
they are all here: he knew it thirty years ago. Two men in Wall street will 
furnish him with all the money he wants. He is to be the next President, Silas 
Wright Vice President, and I (the attendant) am to be his family physician. 
Steamboats are to be made of cast copper, and all in one piece, so that they will 
not leak. They are to be one thousand feet long, four hundred wide and four 
stories high. These boats will go faster than the fastest horse, and he has seen 
horses that would go over thirty miles in an hour. The land on the globe is worth 
$470,804,084,680: (the patient making the figures.) To this the value of every 
precious thing, &c, may be added." 

By the first of February he was altogether better than at any previous 
time since admission, and continued so throughout the spring, with occa- 
sional brief relapses. He rarely uttered his extravagant ideas unless very 
confidentially to those who were most intimate with him. He was, how- 
ever, as he had been for months before, very mischievous and cunning: 
concocting various schemes to make his escape, which, however, generally 
failed for want of foresight. He amused himself for hours, daily, in roll- 
ing nine-pins, and was very expert at the game. At length, in May, he 
effected his escape by scaling the fence beside the bowling alley: went 
home, made some imprudent purchases, conceived a plan for enlarging his 
house, and was about to tear part of it down, when he was brought back. 

About the middle of June, he again began to grow worse, was stupid, 
and constantly inclined to lie down. When spoken to, he would laugh, 
but did not appear fully to understand what was said to him. After 
being purged and put upon diet, he became better. 

During his relapse, his speech was much affected, gradually declining 
until it became a mere mumble. 

Nov. 12th, 1847. — Says he shall soon go to the city, be admitted as a 
counsellor of law, open an office in Wall Street, with a large library, 
have an assistant and do a great business ; that he will buy one hundred 
thousand dollars worth of real estate of the city corporation, and contract 
for the opening of avenues and cross-streets, and thus make two hundred 
thousand dollars more ; that he will buy a house on Bleecker or Fourth 



1849.] Earle's Cases of Partio- general Paralysis, 89 



Street, keep a carriage, have a country seat at Flushing, with a farm of 
two hundred acres, and that he will buy property near Bloomingdale, 
and establish an asylum for the deaf and dumb. 

He furthermore says, that in Illinois, there are twelve thousand acres 
of mineral lands, with mines of coal, copper, brass, zinc, lead, and pew- 
ter; he will go there, purchase the land, build furnaces, and work the 
mines. Next year he thinks he will build six steamers, to ply between 
England and New York. He offers offices to several of the inmates of 
the asylum. 

26th. For some time past he has talked pretty well ; his speech is now 
greatly affected, and similar to that of a man much intoxicated. 

Throughout the winter he was subject to changes, being better and 
worse alternately, but, upon the whole, gradually failing, both body and 
mind. As the spring approached this decadence became more evident. 
He was subjected to no medical treatment except an occasional cathartic. 

April 2d, 1848. For two days past, he has been unable to dress, 
undress, or feed himself. He stoops much when standing ; when walk- 
ing, totters and sometimes falls. The muscles of his face, and particularly 
around his mouth, are constantly twitching. If he endeavours to show 
his tongue, after much exertion it is at length protruded with a sudden 
spasmodic jerk, all the muscles in the face having a similar action. In 
attempting to lift the arm, the same phenomenon occurs in the muscles of 
that limb. His mind is very feeble, inactive, partially bewildered, and 
half unconscious. 

He was now put upon the use of wine. 

April 5th. Is better, walks more firmly, assists himself. 

8th. Removed by his friends from the asylum. 

During the whole period of his residence here, he occasionally wrote 
letters to his friends, and, as his disease progressed, his chirography 
gradually deteriorated, until it became a mere scrawl, and, finally, he was 
entirely unable to guide the pen. The following is one of the last of his 
legible communications. 

"Datorlen 28th Sept ber 

D ear 'Wife — I take pen in hand to Inform that friday the Day that you are 
come up for and Bringe up six three for me 

No more present 

Mr. J*##S****** 

You will please to atten to end to so a to Bring 

them up 

j j} * * * 

Rus yrs Respec fily." 

General sensation was somewhat obtunded, but not to so great an 
extent as in some similar cases. The inequality of the pupils, observed 
on admission, continued until he left. 

From the time he left, he could never dress or undress without assist- 
ance, nor could he help himself to food after the first few days. He 
afterwards sometimes attempted it, but the power accurately to control 
the muscles was gone, and the food was thrown from his hand, either 
by tremulousness, or by a spasmodic jerk. — The instability of gait con- 
tinued, and he fell many times while walking. At times, he could not 
walk without assistance. — -The defect of speech was variable, being on 
some days so great that his wife could not understand him. The muscles 
of the mouth and tongue acted spasmodically when he endeavoured to 



90 



Earle's Cases of Partio- general Paralysis. 



[Jan. 



speak. — He several limes attempted to write, but could not guide the 
pen. — He ate with equal relish all kinds of food, even such as he would 
never taste when well. His appetite was voracious, bowels not habitually 
costive, evacuations natural. 

The exalted ideas of wealth continued as long as he could speak, but 
the general character of his mental operations was that of childishness 
and imbecility. — From about the 10th of June his evacuations were 
passed involuntarily. — On Tuesday evening, June 27th, he did not appear 
quite so well as usual, and at one o'clock, the following morning, he was 
seized with convulsions, hemiplegia of the left side, and entire oblitera- 
tion of the mental faculties. The convulsive spasms of the right side 
continued, though much abated in severity, until the day of his death, 
July 2d. 

Jlutopsy, 17 hours after death. Embonpoint mediocre. — The cranium 
is anormally adherent to the dura mater, though not excessively so. It is 
of medium thickness, and the channels of the blood-vessels are deep. 

The dura mater adheres, by strong filaments, to the anterior portions of 
the anterior lobes of the cerebrum. There are also adhesions for three 
inches upon the vertex, beside the median line, upon the proximate bor- 
ders of the two hemispheres. These are so close, that they involve some 
of the blood-vessels, and so strong as to be detached only by dissection. 
In the substance by which these attachments are made, there are some 
small white granules. 

The dura mater being removed, the pathological condition of the mem- 
branes exposed to view, is such, that the cerebral convolutions are but 
partially visible. The blood-vessels are congested, and in some places 
contain air; the arachnoid is everywhere thickened, in some places 
semi-opaque, translucent (not transparent), and in many perfectly opaque. 
It is so firmly united with the pia mater, wherever they are in contact, 
that the two appear to constitute but one membrane, which is thick, tough, 
and almost as difficult to be cut as the dura mater. Over the sulci it is 
elevated by effused serum. 

The pia mater is somewhat adherent to the brain beneath, but, upon 
removal, does not bring with it any portion of the cineritious substance. 
The anfractuosities are deep and the vessels of the pia mater within them 
are highly congested. There are no adhesions to the falx, but, beneath 
its anterior extremity, the membranes of the two hemispheres are attached 
to each other. The cortical matter is thought to be of its natural color 
and consistence. 

The medullary substance, upon section, appears of a pinkish color, so 
that the line of division between it and the cortex is less definite than 
usual. — Many bloody points on the surface of the section; more than in 
most cases, fewer than in some. — The medullary matter of both hemi- 
spheres, including the corpus callosum and fornix, is softened, and that 
softening is very considerably advanced in the centre of the middle lobe 
of the right hemisphere and the adjacent part of the corpus striatum. 

The approximate portions of the brain about the choroid plexus, fornix, 
and optic thalami, are connected with each other by numerous filamentous 
bridles. — A. similar condition is found in the fourth ventricle, and in the 
central region of the base of the brain, particularly around the pons Varolii. 

The lateral ventricles are distended by serum, the aggregate of which, 
in all parts of the brain, is four ounces. 

The membranes at the base of the brain are far less diseased than 



1849.] Robson, Chloroform in Amputation of the Thigh. 



91 



upon the other portions, yet there is much thickening and semi-opacity 
(with, as usual, a milky or opaline appearance) in the central region and 
in the fissures of Sylvius. — Cerebellum thought to be somewhat softened, 
its investing arachnoid slightly thickened. 
Thorax. Lungs large and healthy. 

Heart of medium size, its muscular tissue pretty easily broken down 
between the thumb and finger. A large, light-coloured coagulum in the 
right ventricle, which extends some distance into the pulmonary arteries. 

All the valves have lost their transparency. — The mitral is cartilaginous 
throughout. 

The lining membrane of the aorta is deeply injected, and there are 
some small plaques of incipient ossification just above the semilunar 
valves of the aorta. 



Art. XII. — Chloroform Inhalation in Amputation of the Thigh. By 
Robert Robson, M. D. 

On the 13th day of July last, I was called by an intelligent friend, (Hugh 
Rounolds, M. D., of Graysville, 111.,) to see with him, at the house of 
August Degan, Wabash County, Illinois, a case of partial anchylosis of the 
knee-joint, caries of the upper third Of the tibia, with hypertrophy of the 
superior portion of the inferior part of the bone, and extensive ulceration, 
&c, of the soft parts. 

The patient, James Gray, is a youth of nineteen years of age, originally 
of good constitution, but in consequence of much physical suffering from 
an injury received near twelve months prior to the date of our visit, we 
found him much reduced, his general health impaired, his pulse feeble, his 
countenance cachectic, and his nervous system much disturbed, though his 
digestive apparatus performed its office as well as could, under such cir- 
cumstances, be expected; but, notwithstanding, his health was rapidly de- 
clining. 

Consultation having been premised, and amputation determined on, the 
patient was placed upon a table, in a recumbent posture, his head and 
shoulders reposing on pillows, the tourniquet, &c, arranged; when we 
proceeded to exhibit a small teaspoonful of chloroform, in a sponge, to his 
mouth and nostrils : but in little more than one minute he became sick and 
vomited, and the sponge was removed during his efforts to vomit; and the 
chloroform having measurably if not entirely escaped, it was again charged 
with the same quantity and exhibited as before, when vomiting again oc- 
curred. The above circumstances were repeated, and the inhalation carried 
on with short intermissions, during which, several drachms of the chloro- 
form were consumed. The time occupied by this exhibition was nine 
minutes and thirty seconds, when the patient assumed the appearance of 
sound sleep. It was now ascertained that he was in a state of complete 
insensibility, and unconsciousness established. 



G2 



Robson, Chloroform in Amputation of the Thigh, [Jan. 



With the assistance of Dr. Rounolds, I then proceeded to amputate the 
thigh, and take up the arteries; the operation occupying two minutes and 
a half. The application of cold water was now freely made to the stump, 
and had been applied but four minutes, at the time the sponge was removed 
from his mouth and nostrils (our supply of chloroform being exhausted), 
when he recovered from the effect instantaneously. At this moment Dr. 
Rounolds inquired of him whether he was still desirous of having his thigh 
amputated, and he replied that he was, and hoped we would not keep him 
longer in suspense. On being informed that the operation was completed, 
and that nothing remained but to dress the stump, he indicated some doubt 
of the truth of the assertion, when some one present elevated his shoulders 
while I raised up the stump, to the evident surprise and pleasure of the 
patient. The dressing was in proper time commenced and completed after 
the manner recommended by Liston. The patient was afterwards attended 
by Dr. Rounolds, and I cannot better express the happy termination of this 
case than by quoting the Doctor's own w r ords in his letter of Aug. 3d. 
He says : " The day after the operation I called to see our patient, and 
found him free from fever, little or no pain, clamorous for something to eat, 
and without the slightest appearance of constitutional derangement. He 
had not taken the opiate which I left him. On the 20th July I removed 
the dressing, and found the stump nearly healed by the first intention; little 
or no pus was secreted, except at the two corners. One or two granula- 
tions I touched with argent, nit. On the 28th of July I paid him my last 
visit, and found him hopping about on his crutches, and moving the stump 
with facility. You will recollect we operated on the 13th of July. On 
examination I found the stump beautiful, hard and firm, perfectly healed, 
with the cicatrix running straight across the marrow line of its face. The 
cicatrix is of course tender, but with this exception, he is in fact well." 

Remarks. — The above case of amputation of the thigh, performed with- 
out pain and without the knowledge of the patient, and his very rapid re- 
covery, has excited much interest in this section, and illustrates in the hap- 
piest manner the influence of chloroform over the brain and nervous system. 
No unpleasant symptoms (with the exception of the vomiting), were mani- 
fested during the inhalation; on the contrary, his respiration, his pulse 
and general appearance were those of natural sleep, and continued unim- 
peded during his insensibility. 

His nervous system remained quiet and undisturbed throughout, and 
undoubtedly facilitated the healing process. In the American Journal of 
Medical Sciences of July, 1848, page 35, we have a statistical table of 
amputations of one of the New York hospitals, from January, 1839, up to 
January, 1848, and the shortest period of cure there recorded is thirty- 
nine days; while our patient, under the use of the chloroform, recovered 
in the very short period of little more than fourteen days. 

New Harxoxt, Indiana, Aug. 25th, 184 8. 



1849.] Blackman, Exsection and Disarticulation of the Lower Jaw. 93 



Art. XIII. — Exsection and Disarticulation of the Lower Jaw for Osteo- 
sarcoma. By Geo. C. Blackman, M.D., Fellow of the Royal Medical 
and Chirurgical Society of London. 

On the 25th of March last I removed one-half of the lower jaw from 
a son of Mr. John P. Cole, of Wantage, Sussex Co., New Jersey. The 
boy was about fourteen years of age, and appeared to be in the enjoyment 
of tolerably good health. About three years previously his parents had 
first discovered a slight enlargement near the left angle of the jaw, and this 
had increased, till at the time of my visit it had attained the size of a goose- 
egg. The boy assured me that he had never suffered any pain in the tu- 
mour, and it was only on account of its recent rapid growth that it had 
begun to be the source of much anxiety. I was informed that for the last 
six months its development had equalled that of the two and a half years 
which had preceded. On this account I advised its removal. With the 
assistance of the family physician, Dr. Cooper, and several physicians of 
the vicinity, I proceeded to operate. The patient having been very readily 
brought under the influence of chloroform, I made a semicircular incision 
which extended from the zygoma over the tumour to a point below the 
symphysis of the chin. The hemorrhage which followed this first incision 
was considerable, particularly from the facial veins. That from the facial 
artery soon subsided of itself, without the application of a ligature. The 
bone having been exposed throughout its extent, was divided near the sym* 
physis with a metacarpal saw, and the dissection along its inner surface 
completed to the articulation. Only one vessel, a branch of the internal 
maxillary, required to be tied. Although during the greater part of the 
operation the patient was insensible to pain, yet when it was completed he 
appeared to be greatly prostrated. He soon, however, rallied when the 
wound was tightly dressed, and he was put to bed. With the exception 
of a slight erysipelatous attack his recovery was rapid, a considerable part 
of the wound having healed by the first intention. The lad called upon 
me last week, and now, nearly eight months after the operation, there is 
scarcely a vestige of deformity remaining. When viewed in front, the line 
of incision is completely concealed, and several persons who have examined 
him, were at first unable to decide on which side of the face the bone had 
been removed. Mastication is performed with the greatest ease on the 
right side, and in every respect the condition of the boy is most gratifying. 
The external surface of the bone removed was of a dark red colour, and 
a section through its inner portion clearly revealed its osteo-sarcomatous 
nature. Contrary to our expectations, nearly the whole body of the ramus 
was involved in the disease. 

What advantage could possibly have been derived in this case from the 
No. XXXIII.— Jan., 1849. 7 



94 



Griffin on Vaginal Hysterotomy. 



[Jan. 



ligature of the primitive carotid as a preliminary step in the operation ? In 
another case, where some four weeks previously we were obliged to dis- 
articulate the bone, only one ligature was required; and judging from the 
little difficulty of guarding against any serious hemorrhage, which was 
found in both these cases, in future operations of the kind, we certainly 
should hesitate before we attempted to carry out the recommendation of 
Dr. Mott to secure the carotid, or the proposition of Mr. Liston to tie the 
common trunk of the temporal and internal maxillary. As the final result 
of the other case to which we have referred is still uncertain, we defer its 
report to a future number of the Journal. 
Newburgh, Nov. 8th, 1848. 



Art. XIV. — Vaginal Hysterotomy. By John H. Griffin, M. D., of 
Salem, Roanoke County, Virginia. 

I was requested on Wednesday, May 10th, 1848, to visit Mrs. W., of 
Montgomery County, a young married lady of good constitution, in labour 
with her first child ; but owing to existing professional engagements, was 
unable to go so far from home (twenty-six miles) on that day; being again 
sent for, however, that night, I reached my patient on the afternoon of the 
next day. 

I found Drs. Eady, Kent and Jackson in attendance. Labour had com- 
menced at midnight on the previous Monday, and, up to that time, although 
the pain had been strong, no appearance of the " os tincae" had been de- 
tected. After repeated careful examination, I was fully satisfied that the 
mouth of the uterus was altogether wanting. The external parts were 
rigid, and extremely sensitive to the touch; but within, what I supposed 
to constitute the neck of the uterus, was found soft, and spread out into a 
thin smooth membrane, through which the head of the child could be dis- 
tinctly felt, and, between the two, during the existence of a pain, the bag- 
like projection of the distended membranes. But, after the most diligent 
search, no opening could be found, and nothing to mark the place where 
it should have been, except a slight degree of roughness, and apparent de- 
pression, at a spot not larger than a squirrel shot. 

All the gentlemen present, having satisfied themselves of the condition 
of the patient, concurred in the opinion that the operation of vaginal hys- 
terotomy should be no longer delayed, and requested that I would per- 
form it. 

After having the woman properly placed, I carefully sought for the rough 
depression above referred to, with the hope that I might be enabled to in- 
troduce a probe pointed bistoury, and thus effect the necessary division of 



1849.] 



Griffin on Vaginal Hysterotomy. 



95 



the neck of the uterus, from a spot clearly indicating where the opening 
should have been. But in this I was disappointed, not being able to detect 
any opening, and was at length forced to substitute the sharp pointed for 
the blunt bistoury: — both of which had been previously prepared by 
wrapping them to within a short distance of their points. This was car- 
ried down to the same spot, between the fingers, and a free bi-lateral sec- 
tion made which was afterwards somewhat enlarged, the probe-pointed 
bistoury being substituted for the sharp. No hemorrhage, worth mention- 
ing, occurred, and, the section being made during the existence of a pain, 
the operation was performed without the knowledge of the patient. 

The pains were now strong and frequent, and, although the presentation 
was the 6th of Baudelocque, and from the excessive rigidity and tender- 
ness, it was impossible to induce the patient to submit to the entire intro- 
duction of the hand, in order to change it to one more favourable, yet it 
was thought best to delay any further interference, for a short time, with 
the hope that the natural efforts of the uterus would be adequate to the ex- 
pulsion of the head. Disappointed in this, the mouth of the uterus being 
fully dilated, the application of the forceps was proposed, and I proceeded 
to introduce the blades, amidst loud complaints of suffering. Some diffi- 
culty was experienced in locking them, and the patient, worn out by long 
suffering, with that impatience which might have been expected sooner to 
manifest itself, insisted that the instruments should be transferred to Dr. J. 
The blades were therefore reluctantly withdrawn, and handed over to that 
gentleman, who, after some effort, not succeeding in introducing them, 
again offered me his place at the bed-side, with the hope that my second 
effort would prove more fortunate than the first; but, as I was about intro- 
ducing the second blade, the patient positively refused to submit to the 
operation, and her husband, also a physician, alarmed lest further delay 
should endanger the safety of his wife, now insisted that the crotchet 
should be immediately resorted to. My remonstrances were of no avail, 
and the head \vas extracted, mainly by the efforts of Dr. Eady, after 
seventy-two hours of suffering, to the great relief of the mother, and delight 
of the friends present; but mingled, in my own case, with regret for the loss 
of the child, which, if alive at the time of the operation, ought, I think, to have 
been saved. The mother fortunately recovered, without any symptoms, so 
far as I have been able to learn, worthy of particular remark. The catamenia, 
which had been regular previous to marriage, returned in a few weeks. 

I am informed by Dr. W. that, during the early stage of pregnancy, Mrs. 
W. complained of uneasiness and pain within the pelvis, which, at the 
time, was referred to the bladder; but which the occurrence above detailed 
renders probable was, in fact, inflammation of the neck of the uterus, by 
which the os was entirely obliterated; no opportunity has been presented 
for ascertaining its present condition. 

This, according to Professor Bedford, of New York city, is the third 
time this operation has been performed in America. 



98 



McSherry on Amputation in Gun-shot Wounds. 



[Jan. 



Art. XV. — Amputation in Gun-shot Wounds. By Richard McSherry, 
M. D. P. A., Surgeon U. S. N. (Communicated in a letter to the editor.) 

In the October number of your valuable Journal, under the head of" Sur- 
gery" in the Quarterly Summary, is an interesting paper by M. Malgaigne 
on the question of " amputation in gun-shot wounds." This paper re- 
called to my recollection that, during the late campaign of Gen. Scott, in the 
city of Mexico, it was a constant theme of remark among the surgeons in 
attendance, as well as of the whole army, how extremely fatal gun-shot 
wounds were in that climate; and many were the surmises in regard to it. 
At one time a large number of the soldiers believed the balls were poisoned 
by the Mexicans, and it was generally asserted that they were made of 
copper. Many officers thought the fatality was owing to some specific 
effect of the climate. My own conclusions are different as to the copper 
balls. I picked up out of curiosity at the castle of Chapultepec, imme- 
diately upon its capture, a rough, queer-looking grape-shot of suspicious 
colour, that I felt sure was copper, but which appeared upon examination 
to be bell-metal; for during the armistice the Mexican General had caused 
a number of bells to be run up to give him a supply of ammunition. 

As to a specific cause, in the climate, I think we may safely set that aside 
when we take M. Malgaigne's little statistical table of the results of am- 
putations for traumatic lesions in the Paris hospitals, for the ten years from 
1836 to 1846. For example, there were thirty-four deaths out of forty- 
four amputations of the thigh; forty-two out of sixty-seven amputations 
of the leg; seventeen out of twenty-nine of the arm, and so forth. Now 
according to my experience and observations, the fatality here was quite as 
great as in our army, except in amputations of the thigh, which were almost 
invariably fatal, whether primary or secondary. This may be accounted 
for, in part, by the fact that our wounded had not the co-mforts and rest 
of the Parisian hospitals. During and after the battles of the valley of 
Mexico, they were of necessity much exposed and had to be transported 
in wagons or ambulances from one position to another; were sometimes 
exposed to vicissitudes of weather, both before and after dressing their 
wounds, and had many unavoidable disadvantages as to diet, clothing, &c. 

Be the cause what it may, it is very certain that cures after severe inju- 
ries of the knee or thigh were very rare indeed ; so much so, that, like 
Ribes, I did not see a single one, in my own practice, or that of any 
other surgeon, whether amputation was performed or not. Possibly some 
of the surgeons may have a different experience. I can only say that 
although I remained in the city of Mexico eight months after the battles, 
and walked the hospitals, I did not see one soldier restored to health after 
a gun-shot wound of the thigh involving fracture. 



1849.] 



Worthington's Case of Intussusception. 



97 



As to all other wounds, not fatal in their nature, they resulted as favour- 
ably as in other climates. My own conviction is that not one case out of 
twenty proved fatal when there was no further injury than amputation of the 
arm. There was not a fatal case under my attention or observation. 

If all the surgeons who accompanied the army on the march were to 
give in their experience, the practical deductions would be, most probably, 
that, while certain most formidable injuries of the thigh, or particularly 
of the hip or knee, make the case hopeless without amputation, yet that 
in most cases, the patient would stand as good a chance of recovery with 
his leg as without it; and that therefore we adopt the better policy by 
attempting to save, at once, his life and his limb. 

U. S. Naval Hospital, near Norfolk, Va., Nov. 1848. 



Art. XVI. — A Case of Intussusception. Communicated by Wilmer 
Worthington, M. D., of Westchester, Penn. 

The following case presents a feature so unusual, that I have thought its 
publication might be acceptable to the profession. Should you be of this 
opinion, you will please give it a place in your valuable Journal. 

A male child aged three years and four months, of rather delicate con- 
stitution, was passed over by a horse in the street, near two years ago, and 
very much contused upon the back, and in the left iliac region. From 
that period up to the first of November last, he had frequently complained 
of pain in the abdomen in the immediate vicinity of the injury, when the 
pain became greatly aggravated, accompanied with occasional vomitings. 
For these symptoms the mother had administered large doses of laudanum, 
without any apparent benefit. Some time in the latter part of December 
or the beginning of January my attention was called to the child. Sup- 
posing worms to be the principal cause of his sufferings, I directed medi- 
cines for their removal, and these were varied according to circumstances, 
without any material change in the symptoms, or relief to the little sufferer. 
About six weeks previous to his death, a diarrhoea came on with discharges 
of bloody mucus. The pain was still severe in the same region as formerly, 
and great tenesmus accompanied his efforts to evacuate the bowels. Two 
large lumbricoid worms were now passed, one of which was coiled into a 
knot. These were the only worms which made their appearance during 
his illness. Prolapsus ani took place about this time, which was mentioned 
to me by the mother: but having directed her to replace it immediately 
after each evacuation, I never saw it in a prolapsed state. The child had 
greatly emaciated, and its sufferings were intense. I placed it upon the 



98 



Worthington's Case of Intussusception. 



[Jan. 



use of hyd. sub. mur. and opium, which I continued for some time, and 
finally exchanged them for a solution of sulph. morph., which was contin- 
ued pro re natd to the time of the child's death, which took place on the 
tenth of July. The warm bath, fomentations, with a variety of other treat- 
ment had been used without benefit. 

Twenty-six hours after death I made a post-mortem examination. The 
omentum majus was found diseased, the result of inflammation. The 
stomach, duodenum, jejunum, and part of the ileum were but little affected ; 
a slight shade here and there of inflammation appeared. The lower part 
of the ileum, ccecum, colon, and rectum, were inflamed, particularly the 
ccecum and colon ; the former approaching a state of gangrene. The cce- 
cum was inverted into the colon, passing through its whole length and 
lodging in the rectum near the anus; carrying with it the lower part of 
the ileum, and a large portion of the inverted colon. The ccecum, all the 
colon except about ten or twelve inches of its lower part, and a consider- 
able part of the ileum, had passed into the lower portion of the colon and 
the rectum, making altogether more than two feet of inverted bowel. 

The liver, spleen, pancreas, kidneys, and bladder, were all healthy. The 
stomach and bowels were entirely empty. No worms were found. No 
food had been taken for about two weeks. 

From the appearances which this examination presented, I came to the 
conclusion, that the ccecum must have passed through the sphincter of the 
anus during the child's efforts to evacuate the bowels. With a view to as- 
certain this fact, I have since inquired of the mother what appearances the 
prolapsus presented, and from the description given, I have no doubt of the 
correctness of this opinion. Indeed, from the position of the parts as re- 
vealed upon dissection, I cannot conceive how it could be otherwise. The 
women who officiated after its death, replaced the protruding bowel, and 
they corroborate the mother in their statement of its unusual appearance. 

July 18th, 1848. 



1849.] 



99 



REVIEWS. 

Art. XVII. — A Treatise on Etherization in Childbirth. Illustrated by 
Jive hundred and eighty-one cases. By Walter Channing, M. D., 
Professor of Midwifery and Medical Jurisprudence in the University at 
Cambridge. " Give me the facts," said my Lord Judge: " your reason- 
ings are mere guess-work of the imagination." — Old Play. Boston, 
1848: William D. Ticknor and Company, 8vo. pp. 400. 

Upon the addition of any new agent to the lists of the materia medica 
it is extremely difficult, at first, to arrive at a correct judgment in regard to 
its true remedial properties, or the circumstances under which alone its 
employment is safe and proper. It is only after the one-sided statements, 
and overstrained eulogies of its early advocates have been corrected by the 
cautious and repeated results of sober experience, that an accurate estimate 
of its real value can be formed. This has been strikingly evinced in 
the case of the several anaesthetic agents recently introduced as a means by 
which pain may be certainly banished from the operations of surgery, the 
process of parturition exempted from suffering, and many of those terrible 
affections which have, heretofore, in a great measure, resisted the curative 
means possessed by the physician, are to be placed entirely under his con- 
trol. A wild enthusiasm appears to have taken possession of the early 
advocates for the use of the anaesthesia in surgery and obstetrics, which has 
led them to view anything less than an instant and implicit confession of 
faith in all they were pleased to claim for these agents, as an opposition to 
truth that should not be tolerated ; and this, perhaps, more than any- 
thing else, has prevented the general adoption of etherization, the recogni- 
tion, ere this, of its true value by the profession, and the settlement of the 
class of cases in which it may be safely and profitably employed for the pre- 
vention of pain. 

So far as regards the use of etherization as a means of controlling the 
pains of childbirth, the questions involved, though important, are still so 
very simple, that we can conceive of no difficulty in speedily arriving at 
their satisfactory solution. Pain is unquestionably an evil; and its pre- 
vention is always justifiable, provided it can be effected without the risk 
of causing injury or serious inconvenience to the patient. Hence, the only 
preliminary points to be settled in reference to the use of etherization in 
parturition are, 1st. Will it abolish the pains of labour, without, at the 
same time, suspending or retarding the expulsive action of the uterus? and 
2d. Can it be employed without danger to the mother and child? The 
answer to these questions is, however, to be derived from the results of 
experience alone. No light whatever can be thrown upon them by a 
priori reasoning. If it can be shown that in numerous instances etheriza- 
tion has been resorted to during labour, with the invariable effect of pre- 
venting pain, without, in any case, causing injury to either the mother or 
the child, we have an unquestionable warrant for its employment in child- 
birth. This cannot be opposed by mere theoretic views as to the probable 



100 



Reviews. 



[Jan. 



danger of the practice, or by our inability to explain how sensation and 
voluntary motion can be suspended, by substances inhaled into the lungs, 
without any interruption occurring in the organic power. The leading 
fact of the efficiency and safety of etherization as a preventive of pain 
being settled, the minor questions as to the proper anaesthetic agent to be 
selected, the time and mode of its employment, and the cases, if there be 
any, in which the abolishment of pain by this means, is of doubtful pro- 
priety or positively forbidden, can be very readily solved. 

Our warrant for a resort to etherization in childbirth must be based on 
the results, not of a few cases, nor even of a number of cases, but of a 
large accumulation of experience as to its usual effects. And until this 
experience has been attained, the advocates of etherization will certainly 
pardon the hesitation of the more cautious members of our profession, 
who, with Professor Meigs, though still unconvinced, hold themselves " in 
readiness to yield to conviction upon sufficient evidence being adduced of 
the necessity and propriety of etherization in midwifery." 

To furnish that evidence is the object of Dr. Channing's publication. 
And we admit, that although the body of facts which it presents, are far from 
constituting all the data by which the necessity, propriety, and safety of 
etherization in childbirth are to be fully established, they are, nevertheless, 
all important and deserving of the most serious and candid consideration. 

In the introductory chapter, in which the plan and object of the work 
are indicated, Dr. C. informs us, that his first intention was merely to pre- 
sent to the public a detailed account of the numerous cases of labour in 
which he had employed etherization, and which had gradually accumulated 
since the publication of the second edition of his pamphlet on this subject, 
in July, 1847. But the thought occurring to him, that with very little per- 
sonal trouble, he might collect from various sources, facts in regard to 
etherization, which would in a much surer manner, make his book useful, 
than would anything of his own which it might contain ; he accordingly 
prepared and addressed to many physicians in Boston and its vicinity, a 
circular containing questions which embraced some of the most important 
points regarding the use of ether and chloroform. 

" My great, I had almost said my sole object in this circular — in short, in my 
whole efforts" Dr. C. remarks, u was to ascertain here at home, in the birthplace 
of etherization, what had been the precise results of many experiments, made by 
many physicians, of the employment of the remedy of pain. My object was to 
learn if this use of it had been safe — safe both to mother and to child ; and thus, 
as far as such results might reach, to contribute something towards settling the most 
important point concerning its further use, namely, that of its safety. 

u This matter of safety is especially dwelt upon, because much that is related to 
it, if not all else, has very little in it requiring present discussion or argument. 1 
consider other questions, as in an important sense settled, and, therefore, not de- 
manding special attention. Thus we know that pain may be abolished by ether- 
ization; we know that voluntary or animal power is very much, if not wholly, 
suspended during this state; we know that organic power remains. Nay more, 
we know that it is often increased, that of the womb for instance ; and in the ex- 
ceptional cases in which uterine contraction is diminished, or in which it entirely 
ceases, we know that this is temporary, and that no danger to either mother or 
child has hence ensued. We know, finally, that during and in consequence of 
etherization, circumstances highly favourable to safe as well as to easy labour 
arise. Among these may be enumerated the increase of secretions in the organs 
immediately concerned in labour, and a more perfect relaxation or dilatability than 
existed before its use. Dubois first made this last observation, and my latest ex- 
perience of etherization confirms his early and important statement." 



1849.] Channing's Treatise on Etherization in Childbirth. 101 



Although it was to the question of safety, in the experience of the New 
England practitioners, that Dr. C.'s attention was directed in the questions 
in his circular, yet he warns the reader from supposing this to be a very 
simple or a single question. 

11 It has regard, indeed, he remarks, to a single fact, the well-being of mother 
and child. . But to show that, in its uses here, etherization has been safe in mid- 
wifery practice, is to declare a most important fact. Safety in this matter involves 
whatever exists or is done in etherization, as a condition towards this great end. 
These conditions are few, and cannot be too often repeated. They are, 1st. Purity 
in the article used. 2d. Such an instrument as will allow the freest escape of the 
expired or exhaled air, and the due admixture of atmospheric air with the inhaled. 
A hollow sponge for ether answers every purpose; for its structure is such as to 
ensure these conditions. 3. When etherization is produced, inhalation is to cease. 
This state is declared by the relaxed condition of the limbs, the inability to raise 
the eyelids at command, and cessation of complaint. The books are full of other 
conditions, and in these the diversity of individual observations and views is suffi- 
ciently declared. Suffice it to say, concerning the mode of exhibiting ether vapour, 
that, of the two methods recommended in midwifery, the one by Professor Simp- 
son, which directs so much to be used, and after such a manner, as shall in the 
shortest time produce the fullest effects — and the otherrecommended by observers 
here in the same practice, which seeks its object by a less quantity, and that, mode- 
rately administered. I think, of these the latter is decidedly to be preferred." 

It was at first the intention of Dr. C. to publish along with his own 
cases, tabular views of what he had been so kindly and liberally favoured 
with in answer to his circular, together with the accompanying letters, and 
here rest the case. It was an afterthought to devote some pages to a few 
of the topics which his subject directly involves. 

Dr. C. has not confined himself to etherization in childbirth. He has 
also noticed its employment in Surgery and general medicine. He has 
done this, he tells us, for illustration, and especially for its bearing on 
labour, both in regard to its agency, and in explanation, and as argument 
for its safety in practice. 

Although the main object of this introductory chapter is to point out the 
plan and scope of the work, the author has introduced into it a general 
defence of the safety and utility of Etherization, and in stating the sources 
of his facts has, by frequent and somewhat abrupt transitions, furnished us 
with much of the results of his own experience, and his deductions from 
the materials collected from various sources. 

The question as to whether there are any circumstances connected with 
the character of the labour or with the condition of the parturient female 
at the time which forbids a resort to etherization, is an ail-important one. 
Dr. C. answers it, in this chapter, in the following words. 

"With regard to contraindications to etherization which are founded in other 
conditions, whether of coexisting functional or structural disease — whether of 
heart, head or lungs, I have no experience or observation to offer. I have met 
with none. 1 believe I am borne out by facts, when I say. that, in the examinations 
which have been made of those who have died after etherization, it has not hap- 
pened, in more than a single case, that any disease existed in any of the organs 
referred to. whereby to explain ths death. The exception occurred lately in New 
York, and will be referred to more particularly hereafter. And for this, it will 
hereafter be shown, by cases of known and grave structural disease, in which ether- 
ization has been afforded by it, and no suspicion, much less proof furnished that 
any untoward results have been produced, or death accelerated by it. A case of 
confirmed phthisis is this moment under my care, in which chloroform has been 
very excessively and imprudently employed; and from which no other apparent 
troubles than nausea and vomiting have followed. These ceased when inhalation 



102 



Reviews. 



[Jan. 



was omitted; of contra-indications to etherization arising in diseases and lesions 
above alluded to, I have no experience to offer." 

In this same chapter we are presented with Professor Simpson's letter to 
Professor Meigs, the reply of the latter, and also a letter from Professor 
Meigs to Dr. Charming in answer to certain inquiries proposed to him by 
the latter, in reference to the Professor's " trials and views" on the subject 
of etherization. The letters of Dr. Meigs are made the subject of a some- 
what extended criticism. The objections urged in them against the em- 
ployment of etherization to prevent the pains of labour are reducible to 
two. The first, is the danger to life resulting from its use. It being 
shown, Dr. M. remarks, by the experiments of Flourens and Wakley, that 
the aspiration of ether or chloroform, continued but a little longer than the 
period required for hebetizing the hemispheres, the cerebellum, the tuber- 
cula quadrigemina, and the cord, overthrows the medulla oblongata, and 
produces thereby sudden death ; consequently, there is a fear that, in all 
cases of chloroformal anaesthesia, there remains but one irrevocable step 
more to the grave. And, inasmuch as the employment of this agent in 
cases of labour cannot be shown to be indispensably necessary, con- 
sequently we have no right to needlessly risk the possibility of a fatal re- 
sult by a resort to it. The second objection is founded upon the belief 
entertained by the Professor, that there is " some physiological and there- 
fore needful and useful connection of the pain and the powers of parturi- 
tion." " If I am not here in error," Dr. Meigs remarks, " I submit that 
no statistics ought to have a real power to convince." 

The proper reply to Dr. Meigs' first objection would be the proof, either 
that the anaesthetic agents heretofore employed do not affect the functions of 
the medulla oblongata, or their exhibition is capable of being so accurately 
graduated as to guard against the extension of their influence to that por- 
tion of the brain. Dr. Channing has, however, thought proper to follow a 
different plan, and as we esteem the objection a very important one, we 
shall present, in his own words, his observations in answer to it. 

u It will be perceived that the objection of Professor Meigs is wholly and purely 
physiological. Etherization being given, this objection demands for its removal 
the law of succession of its action on the several portions of the brain, from the 
hemispheres to the medulla oblongata, should it happen to reach so far; while 
it is at the same time obvious, that no such law as this can be ascertained. It is 
hence an impossible objection (?), and the true question is, whether it should for a 
moment influence practice. We know not what is the succession of events, from 
the slightest impression made by ether or chloroform on the hemispheres, or upon 
any intervening point between them and the medulla oblongata. We know not, 
and cannot know, where safety ends and danger begins by any known action of 
the agent, or by any law of its action. Examinations after death from etheriza- 
tion show every variety of results, from the slightest, or none at all, to the greatest. 
The heart is found in every condition of emptiness and fullness., and the blood is 
quite as remarkable for the variety of lesion it presents." 

" I have directed as much, if not more attention to the state of the respiration 
and of the circulation, than to any other facts in the history of etherization. These 
functions have always seemed to me to demand the most attention. They de- 
pend on the integrity of the medulla oblongata for their regularity, and for their 
very continuance. Thus I have counted the pulse and the breathing before ether- 
ization. Then while it was getting established, and during its most perfect state, 
I have known them to remain wholly undisturbed in the midst and pressure of 
the total abolition of consciousness and sensibility. The patient has been in a state 
of entire and perfect repose. It has been the completed work of a second. There 
has been no time for succession in action, or it has been too small to be measured, 
or the series of events noted. I have known labour to advance in this state of 



1849.] Channing's Treatise on Etherization in Childbirth. 103 



things and to terminate, and not a limb or a muscle to move, or the face to betray 
the slightest token of suffering. In another part of this volume, 1 have related a 
case in which volition and muscular power partially remained, or was regained 
during deep etherization. The woman was evidently wearied with her position 
on the left side, and in the most methodical manner possible turned herself over 
to the right, and composed her limbs after such a manner as to secure to herself 
a most comfortable sleep; and sleep she did through the whole of the remainder 
of the labour. These cases have been perfectly safe." 

Dr. Channing remarks, that the effects of etherization occur in many 
instances in so short a time after inhalation as to make observation of any 
succession of events impossible. In addition to what is said in the fore- 
going extracts of the state of the respiration and pulse being generally per- 
fectly natural, he adds that sometimes this is not the case. 

"They are sometimes more rapid, sometimes slower than natural. Sometimes 
the breathing is perfectly noiseless : at others it is heavy, stertorous, snoring. Pro- 
fessor Simpson speaks of this as occurring more frequently in his practice than 
has been met with in the cases which have fallen under my own observation." 

" Professor Meigs speaks of the depth of sorrow he should endure, should he 
destroy one in a thousand cases by using etherization in labour. Whence would 
come that sorrow ? Not on account of wrong-doing, certainly. For what better 
argument could he or anybody else have for employing the remedy of pain in the 
thousandth case, than the preceding nine hundred and ninety-nine perfectly suc- 
cessful ones'? Would it not, at once, occur to such experience as this, that the un- 
toward result was in no sense the product of professional delinquency in the em- 
ployment of a remedy; but that it was a result not to be looked for or anticipated ; 
which stands as the solitary exception to the universal rule ; for such would such 
an exception make it; which has hence no relation to practice; and the very ex- 
istence and whole history of which begins and ends with the fact itself? Add to 
this the fact, that in not a single instance of the thousands of recorded cases of 
childbirth, has there been a single untoward result met with during etherization ; 
and what further argument do we want to support the position, that this agency in 
painful labours is not only most reasonably demanded by the sufferer, but that it 
is the solemn duty of the profession to afford to such suffering its certain relief." 

We admit that the objection of Dr. Meigs to etherization in labour can 
be overthrown only by the invariable results of experience. If it shall be 
found, as Dr. Channing asserts it has been, that the employment of this 
agent to relieve the pain of parturition is unattended with danger to either 
mother or child, then, certainly the occurrence of hebetization of the 
medulla oblongata is so improbable an occurrence that it alone should not 
deter any one from the employment of etherization. But if we should 
have any probable reason, founded upon experience, for supposing that ether- 
ization would destroy one in a thousand, unless some better reason can be 
given for iis use than merely the relief of pain, we must say that a resort 
to it would not only be improper, but highly reprehensible. 

In reply to the second objection of Dr. Meigs, Dr. Channing simply 
denies that pain is necessary to the expulsion of the child from the uterus. 

"The functional department of labour is the contraction of the womb, the dilata- 
tion of its mouth, vagina, and external organs, which are no more necessarily 
painful than are those which carry forward and expel the contents of the rectum 
or bladder. There is no pain in the pure functional actions of the uterus. Pain is 
the consequence of resistance to the contractions of the womb, which the moving 
body, the foetus, encounters in its progress to birth. Pain in labour is the result, 
first, of the imperfect harmony of functional dilatability of the mouth of the womb 
with the contractions of the organ; secondly, of a like state of the vagina; and, 
thirdly and specially, of a like condition of the perineum and external organs. It 
is in these contingencies, not natural elements of labour, that the whole pain of 



104 



Reviews. 



[Jan. 



labour has its cause. The pressure of the unyielding head upon the sacrum also 
takes its share in the production of the resistance which makes up the whole pain 
of labour. I do not refer to morbid conditions of the passages, such as excessive 
sensibility and others with which all practitioners of midwifery are so well ac- 
quainted. I merely refer to functional conditions or disturbances, which are ordina- 
rily met with, and which give rise to the agony of childbirth. Now this state is 
one which demands relief. It does not necessarily belong to labour, since pain- 
less, or nearly painless, cases of labour are too common to allow of such a state- 
ment for a moment. It is to relieve the unnecessary suffering which results from 
those conditions referred to, that etherization is employed." 

If the pain of labour is not as Dr. Meigs terms it, " physiological pain" 
— and that it is so we think our author has himself unintentionally con- 
fessed in the passage just quoted — then we must conclude that all labours 
in which etherization is not practiced, excepting the few painless ones Dr. 
C. refers to, are attended with non-natural elements, resulting, however, 
from " functional conditions" which are " ordinarily met with." Now the 
real question is this — can the pains of parturition be annulled without in- 
creasing in any material degree the risk incurred by the mother or child ? 
And this question, like all the others connected with the subject of ether- 
ization in childbirth, can be settled only by the closely and cautiously ob- 
served and faithfully recorded results of accumulated experience. 

There is one point not noticed in this connection, which is urged by 
some obstetricians of eminence, against a resort to etherization in labour, 
and that is, that a state of consciousness on the part of the parturient 
female is important in many cases as a guide to the obstetrician — the cha- 
racter of the pain or its excitation under particular circumstances being to 
him, under many circumstances, a language of weighty import. In cases 
demanding manual or instrumental interference, we can readily understand 
in what manner pain, or at least a susceptibility to pain, may be of real 
advantage. This, we confess, does not form a just reason for rejecting 
etherization entirely from obstetrical practice, but it requires that those 
cases in which it may be properly resorted to should be carefully pointed 
out, and, all the circumstances under which it becomes a doubtful or im- 
proper agent should be accurately defined. 

We need scarcely apologize for the space we have occupied in the con- 
sideration of Dr. Channing's introductory chapter, or for the frequent 
extracts we have made from it, inasmuch as it presents a very full sum- 
mary of the author's own views and the deductions he has drawn from the 
various facts collected by him, and, at the same time, introduces us to his 
mode of disposing of the leading objections to etherization in labour. 

The next chapter comprises a sketch of the discovery and use of ether- 
ization in medicine and surgery. This, though sufficiently interesting, we 
shall not stop particularly to notice. 

In the chapter which follows, the subject of the physiological agencies 
of etherization is discussed. 

From some experiments performed by Dr. Perkins, of Newburyport, in 
which a frog was etherized, and its web then examined by a strong com- 
pound microscope, Dr. Channing infers that, during etherization, there is a 
complete suspension of the capillary circulation. He states, that after in- 
spiring both ether and chloroform, there is experienced a sensation very 
exactly resembling that of a limb in the state of "being asleep," as it is 
called — a sense of tingling or prickling throughout the whole body, espe- 
cially in the extremities, which he believes may be explained by the arrest 
of the capillary circulation, or by its renewal as the effects of etherization 



1849.] Channing's Treatise on Etherization in Childbirth. 105 



cease. A very observing person, who was fully affected by chloroform, 
told him that the tingling, she thought, was observed before any other 
effect. All others who have spoken of it have, we are told, referred it to 
the moment of returning consciousness and sensibility. One individual, 
who was very slightly affected, felt the sensation referred to upon one side, 
the left, only. It embraced the upper and lower extremity, and half of 
the trunk. 

A very common and immediate result of inhaling ether or chloroform is 
noise in the head, sometimes slight, at others very considerable. Dr. C. 
has never known it spoken of as annoying. It is compared, especially, to 
things in motion, as the noise of a railroad car — of a machine shop, a 
cotton mill, &c. He has almost invariably heard it ascribed to any noise 
which has particularly attracted the notice of the person. 

Dizziness or rather confusion is another of the cerebral phenomena. 
Excitement, pleasurable or otherwise, occasionally occurs. But whatever 
may be the condition directly following inhalation, it does not last long, or 
very rarely does so. Unconsciousness, apparent or real, and insensibility, 
put an end to these sensations. 

The condition as to consciousness during etherization is at times perfect. 
Everything said is heard and remembered. At other times consciousness 
is disturbed. One person is mistaken for another, though still spoken to 
with apparent perfect coherence. Other cases present a very different 
state of things. There is consciousness, but nothing betrays it. A perfect 
repose exists. Not a word is said ; not a voluntary act done. And yet, 
when the person comes out of this state, there is the most perfect memory 
of what has been said and done. 

" Whatever," remarks Dr. C, " may have been the cerebral condition or func- 
tions during etherization, I can say, with entire confidence, that 1 have never known 
it to continue beyond the state itself; namely, a few minutes after removal of its 
cause. I have never observed any loss of strength following its use. On the con- 
trary, the absence of pain during labour has been attended and followed by a 
remarkable preservation of strength. The uterus has acted with more true power, 
and patients have returned sooner to ordinary duty — the family — than after any 
preceding labour. In this observation 1 am sustained by that of almost every one 
who has employed inhalation in midwifery practice. I beg this to be especially 
understood and recollected; for it cannot but have a very decided and favourable 
effect upon the continued use of inhalation." 

In another place Dr. C. observes, that: — 

"The etherized person is not drunk — is not intoxicated. There is the helpless- , 
ness of sleep; but there are going on most important functions, and without the 
least disturbance, nay with increased power. The person wakes from this state 
at once. The mind declares itself in its clearness, fulness, naturalness. There is 
not a moment of that apoplectic sleep which follows intoxication — none of that 
surfeited aspect, as if the person, in having been relieved of pain, had for the 
time become allied to the brute, and did not lose the relation when consciousness 
has returned. Especially is this true after chloroform. Etherization by this is at 
once followed by entire return of the faculties. Chloroform very soon disappears 
from the breath, and is found in none of the excretions, showing how evanescent 
is its agency." . 

Etherization suspends sensibility; labour goes on, but without pain. It 
is not uncommon, however, we are told, to hear, during the uterine con- 
tractions, expressions indicating effort. Respiration becomes embarrassed 
by uterine contraction, and this is often perceived in the apparently volun- 
tary effort which attends it. It is precisely the same as occurs during 



106 



Reviews. 



[Jan. 



sleep, when from an unfavourable position of the body, or other cause, 
functions become embarrassed. The brain is at once informed of this, 
and directs the actions necessary to remedy it. The breathing is sus- 
pended, then forcibly renewed, until change of position is obtained. 

During etherization the voluntary muscles are at rest, and volition is to 
all appearance suspended. Dr. C. thinks that there is a degree of ether- 
ization, however, which is not incompatible with voluntary muscular action, 
and sufficient to suspend that degree of sensibility which is attended with 
pain or with pain that is remembered. 

u No one," he remarks, " at all conversant with etherization, has not had 
abundant opportunity to observe, that there are limits which may be placed by 
him to the power. Nay, what is still more remarkable is this: the patient may, 
and does, determine or place this limit herself, just when and where she pleases; 
and in fact, frequently does this when the sponge or the inhaler is in her own 
hand. She lets it fall, when that point is reached. When she does not do so by 
volition, the limit is exceeded, and the instrument falls, by its own weight, and by 
muscular relaxation, from between the fingers. It is this which constitutes one of 
the most important, I may add, beautiful, facts in our subject, and it furnishes us 
with this practical rule, which should never be forgotten ; namely — entire etheriza- 
tion is unnecessary in midwifery, except in instrumental and other difficult cases." 

According to Dr. C, etherization has no necessary effect to diminish 
the organic action of the womb. He has not, in his own practice, met 
with a single instance in which diminution, or a suspension of contraction, 
has occurred, which has differed from those in which the same thing has 
happened without ether. He admits that, in some of the cases detailed in 
the volume before us, he has found it necessary to give ergot. Thus he 
has given it because hemorrhage had followed a previous labour, and in 
some cases because the labour was protracted, or the contractions, though 
accompanied by much pain (?), have been ineffectual, and because the 
pains following its use, have been as easily controlled by ether as are nor- 
mal efforts. He thinks the weight of evidence is against the doctrine or 
opinion, that ether checks labour. 

c: On the contrary, he adds, we find it often recorded that dilatation has pro- 
ceeded much more rapidly during etherization ; that lubrication by secretion has 
become more abundant; that contractions have increased, and labour been more 
rapidly terminated." 

The proper settling of this question, we consider to have a most im- 
portant bearing upon the question, of the propriety and safety of etheriza- 
tion in labours generally. Dr. Charles E. Ware, in answer to Dr. Chan- 
ning's circular, writes as follows: — 

" From my own limited experience, I should say, that the invariable effect of 
the ether was to diminish the force of the pains, and retard the labour, whenever 
the inhalation was carried sufficiently far to diminish, materially, the suffering. 
This consequence has been so unvarying, that it has been difficult for me to be- 
lieve, that the experience of others should differ so widely from my own as has 
been represented to me by many. When the ether has been carried to entire 
insensibility, as it has been repeatedly, the consequence has been, that, for a con- 
siderable interval, I should say fifteen or twenty minutes, at least, there has been 
an entire cessation of pains, when, the intervals before had not been more than 
two or three minutes, and, when pains did occur, they would never bring the 
head down as low as it had been before. In the cases where 1 have used it, I 
have always experimented, frequently at different stages of the labour, so as to 
leave no doubt as to the fact. Twice, in cases of first child,Jhe use of the ether 
has been a source of great comfort to the mother, by giving her long intervals of 
entire repose: after which, she would wake up refreshed to go on with the labour, 
although the disappointment has been great to discover that it was not all over.' 7 



1849.] Channing's Treatise on Etherization in Childbirth. 107 



Dr. Charming endeavours to get over this positive and direct testimony 
of Dr. Ware, by suggesting that the lengthened interval and diminished 
uterine action which he invariably observed, were, probably, the replace- 
ment of the irregular and violent, and so non-natural effort by the normal 
or true action, in consequence of the agency of the will in stimulating to 
excessive and irregular action, being suspended by etherization. Dr. C. 
confesses that he has again and again witnessed this temporary and even 
lengthened interval of uterine effort, and diminution of its force, during 
etherization. But he has viewed it as the natural state of the function, 
which etherization has produced, and has consequently welcomed it. The 
recurrence of uterine contraction has not been with diminished force, and 
has been attended by speedy and painless delivery. Dr. C. admits, that 
the cases of Dr. Ware cannot be referred to the same class as those in 
which, when etherization has not been practiced, a suspension of labour 
pains takes place for a longer or shorter period. They are too many, he 
remarks, to be resolved into mere coincidences. But still, as they differ 
from a wider experience, they are not, he remarks, intended to make an 
objection to the continued use of etherization. 

To prove that etherization does not necessarily suspend or lessen uterine 
action, Dr. C. adduces the evidence of Professor Simpson, of Edinburgh, 
and of Dubois, of Paris, and the case of Stoltz, of Strasburg. 

In regard to the condition of the respiration and circulation during ether- 
ization ; the first, we are told, is usually somewhat hurried in the first inha- 
lations, probably more from mental excitement, than from any direct effect 
of the agent used. When etherization has taken place, the breathing be- 
comes slow and noiseless. Rarely has Dr. C. noticed the stertorous 
breathing, or snoring, described by Professor Simpson. In three cases it 
was present in a very slight degree. The pulse is at first excited, evidently 
from mental causes. The pulse afterwards becomes calm — returning to 
its natural beat, or falls below it. 

' ; One change in the pulse is very striking. It is the diminution in frequency, 
and increase in force, which sometimes attend on etherization. Dr. C. has known 
the pulse fall to between thirty and forty beats in the minute after chloroform. He 
has never observed the change to this extent after sulphuric ether. This slowness 
of pulse in different degrees almost always accompanies the perfect quiet and 
unconsciousness of full etherization. Whenever this state of pulse occurs, if you 
have not removed the inhaler, do it now. The whole state of the patient shows 
that our object is obtained. If the slowness of pulse be noticed in the interval of 
contractions, which is the time of its greatest intensity, a change in the circulation 
at once is declared, when uterine contraction returns; and w T e shall find that the 
natural state of the pulse will be restored, and this the more as the consciousness 
and sensibility return." 

Nausea and vomiting are occasionally induced by etherization. Dr. 
C. has seen only one case of vomiting, and this after chloric ether, and 
not more than one or two attended with nausea. 

The subjects of the next chapter are the production, conditions, signs, 
and results of etherization. Some remarks are made in reference to the 
comparative effects and consequent availability of the different anaesthetic 
agents used for inhalation. 

" Safety in etherization," Dr. C. remarks, " can only come of condi- 
tions." These are found in the article employed, the instrument or inhaler, 
the present state of the patient, and the effects produced. He insists upon 
the importance, as a preliminary requisite, of the entire purity of the par- 
ticular agent employed. Upon this depends, in a great measure, the safety 



108 



Reviews. 



[Jan. 



in its use. It is unnecessary to notice the author's conclusions in regard 
to the best instrument, also the most proper mode of inducing etherization. 
To communicate any useful information to our readers on these points, 
would require a length of detail that would be scarcely tolerated, even were 
it proper, in the review of a work which is within the reach of all who 
feel an interest in the subject. 

After pointing out the fact, that the entire process of labour is a purely 
physiological function, — that its commencement, the dilating of the os 
uteri, the contraction of the womb, are all strictly functional, — Dr. C. 
remarks that, when the os uteri is fully dilated before uterine contractions 
come on, the labour is painless ; but when labour occurs before this dilata- 
tion has been effected, or when from any cause does not readily allow the 
passage of the head, or when the position or presentation of the latter are 
unfavourable, we have irregular, convulsive efforts of the womb, attended 
with great suffering, to relieve which, the will calls into action all the mus- 
cular agencies which can be commanded. In consequence of which, 
strength is wanted, the organs become irritable and tender, the secretions 
are diminished, <fcc. Now, it is in these cases, we are told, that etheriza- 
tion exerts the most happy influences. Contractions are controlled, or 
even suspended, if the labour be wholly spurious, or even when this is 
not the case, but where increased resistance is operating to prevent timely 
delivery, the same useful effect may be produced. 

But if, as is certainly true, the pain and troublesome and alarming con- 
sequences, in the cases just alluded to, are the consequence of violent and 
prolonged contractions of the uterus, caused by a resistance to the passage 
of the head, and etherization has not the power of arresting the actions of 
the womb, but of increasing them, we cannot understand upon what prin- 
ciple its agency becomes, under such circumstances, beneficial, or even 
safe. It may overcome all voluntary efforts on the part of the patient, but 
cannot control uterine action, unless it is presumed that, while etherization 
allows the natural, efficient contractions of the womb to proceed, it con- 
trols all abnormal action, as well as that which from any cause is rendered 
inefficient. 

Dr. C. admits that, while etherization has never been productive of other 
than beneficial effects in cases of labour, it has, occasionally, though 
rarely, been followed by untoward results in surgical cases. This, he pre- 
sumes, may be accounted for by the state of entire health of the patient 
in the first, and the augmented vitality of pregnancy ; while in surgical 
patients, there is often a state of suffering from some local affection, 
often a mere result of internal disease. The operation is itself a violence 
done to sensitive textures, the most sensitive which enter into the com- 
position of the body. There is no interval during which there is a 
perfect rest from suffering, as in labour, and hence, there may be no re- 
spite from inhalation. In regard to the fatal cases which have occurred, 
whether at home or abroad, Dr. C. suggests whether there may not have 
been some constitutional peculiarity, some individual predisposition, which 
led to the fatal result. Is it not possible, that this same peculiarity, this 
same predisposition, may happen in obstetrical cases, as well as in patients 
labouring under diseases requiring a surgical operation ? 

" There can be no sort of doubt, Dr. C. remarks, that the condition which is 
produced by sudden violence — the crushing of a limb by a rail-car, by external 
injuries from powder explosions. &c, — is most unfavourable to the successful 
performance of a grave surgical operation, whether during etherization or not. It is 



1849.] Channing's Treatise on Etherization in Childbirth. 109 



not ether or chloroform which kills here. It is the shock to the nervous system 
which first perilled life, and the operation, which gave the only chance of reco- 
very, would, probably, have been followed by death, let the circumstances under 
which it was done have been what they may." 

To this is to be added the further shock resulting from the fear of the 
operation. 

In some cases of labour, we are told, the first impression, or effects of 
etherization, are very unpromising, and seem not to authorize its further 
employment; when, however, the patient urges its further continuance, Dr. 
C. has permitted it, and with the happiest results. 

In regard to the important question, Is etherization to be induced in all 
cases of labour ? Dr. C. remarks that he has seen nothing in any case which 
has fallen under his notice, which would lead him to the conclusion that 
it is not proper in any case of labour, or that it has been injurious or unsafe 
in any one. The evidence from all others who have been consulted by him 
is to the same general purport. The exceptions which have been reported 
to him do not disturb the rule. 

1 '• They are not designed to do this. They proceed from differences, not con- 
flicts of opinion, and are not stated to influence the practice of others; one only 
says, that he thinks that an equal number of cases of childbirth without ether 
have done better than have those which have been treated by it. Bat he offers 
no evidence that the ether has done harm in any one. ;; 

Various deleterious effects have been ascribed to etherization, as exhi- 
biting themselves subsequently to delivery. Thus it has been accused 
of inducing puerperal mania, puerperal convulsions — and of endangering: 
profuse uterine hemorrhage. Each of these alluded consequences of its 
use is examined by Dr. C. and many important facts adduced calculated 
to throw light upon the important question of the freedom from danger of 
etherization, so far at least as the serious results first alluded to are con- 
cerned. 

"Thus far, he remarks, it may be said of etherization, that it has produced no 
such effects in midwifery practice as for a moment suggest the thought that it 
should be laid aside, or make its entire safety a question. I have not met with 
a case, either of personal observation or of record, in which anything untoward 
has occurred in midwifery during etherization which has not been explained 
without referring it to any malign influence of this condition. Labour has been 
met with having its gravest complications after the use of ether, just as these have 
occurred before its power was known. And, again, these very complications 
have been wanting after etherization, while they have occurred in a most alarming 
form after labour without it. Hemorrhage has been among these complications. 
It is the most frequent of all others. 1 have not met with it more frequently of 
late than formerly, and, of all the cases which have been communicated to me, 
or which 1 have met with in books, I have not found one which without question 
should be ascribed to etherization." 

The following nine propositions, in which the course of Dr. 0. in regard 
to the use of etherization in labour, is indicated, are interesting as present- 
ing, in a few words, the leading conclusions at which he has arrived from 
his own experience, and the facts he has derived from other sources. 

1. " I generally'take with me ether or chloroform, or both, and an instrument 
which 1 have found to be of easy and safe use. 

2. " If I am not desired to employ etherization, and the pains are very severe. I 
offer inhalation as a sure and safe means of abolishing pain ; and this iii perfecdy 
natural labour, and when it is proceeding rapidly and favourably. 

3. " In protracted labour, in which dilatation goes on very slowly, and notwith- 
No. XXXIII.— Jan., 1849. 8 



110 



Reviews. 



[Jan. 



standing very severe contractions and great suffering, I recommend and employ 
inhalation. 

4. " In any labour; if along with imperfect dilatation, or when this is natural, 
but the secretions are deficient, and whether morbid irritability or sensibility exist 
or not, I use inhalation. 

5. " In protracted cases, if dilatation be slow, and the contractions defective, or 
the same character of contractions be accompanied with more ready dilation or 
dilatability, I use inhalation. 

6. "In instrumental labour, I use inhalation; applying always the instruments 
before etherization is begun. 

7. "In those cases of preternatural labour in which turning is necessary, I 
employ etherization. 

8. " In any case in which increased contractions do not attend etherization, or 
in which they are diminished, and in cases in which hemorrhage has followed a 
preceding labour, I give an infusion of ergot; rarely, if ever, with the powder, just 
as I would have prescribed secale, had etherization not been discovered. 

9. " If the patient object to inhalation, I do not press it. For the most part, the 
objection is made in terms sufficiently explicit, before the suggestion to employ 
etherization is made, to prevent its being offered, and, again, its forced use will 
probably fail to produce its desired effects; and so to the untoward, should that 
follow, will have to be added the consciousness of failure, and the sure memory 
of it by others." 

In the next chapter we have an account of the treatment of the abnormal 
effects of etherization. — -These are the occurrence of paleness, lividity of 
the fingers, lips and face, diminished temperature, rapid and feeble pulse, 
a sighing, slow, deep, or a noiseless, almost imperceptible respiration, and 
perfect stillness of the patient. These symptoms may occur suddenly, in 
the beginning of inhalation, or only after a long-continuance of inhalation. 
In the first case they resemble syncope, in the last exhaustion. Inhalation 
is immediately to be suspended upon the occurrence of these symptoms, 
the patient is to be supplied with fresh air, but in such a manner as care- 
fully to avoid chilling her. Heated flannel should be applied to the skin — 
bottles of warm water or heated irons to the feet and inside of the legs. 
Gentle friction should be applied to the surface. Internally, moderately 
stimulating drinks should be administered, but over stimulation carefully 
avoided. 

In other cases etherization produces a kind of hysterical paroxysm, 
attended with great restlessness, jactitation, screaming, crying, laughing 
&c. &c. The skin becomes red, hot and swollen, the eyes are brilliant, 
and the hearing morbidly acute. These symptoms may be treated with 
antispasmodics, and will, we are told, for the most part disappear in the 
time of an ordinary attack of hysteria. Catalepsy has also occurred during 
etherization, as well as other and very severe forms of convulsive disease. 
Dr. C. considers that an expectant or palliative course is the best under 
these circumstances. 

According to Dr. C. these abnormal effects of etherization 

"Can have only a very indirect relation to childbirth, since he has known of no 
case of labour, in which the various affections so distinctly referred to have ever been 
noticed; on the contrary, they have been confined, almost exclusively, to minor 
operations in surgery, as tooth drawing, nail drawing, &c. But adds Dr. C, with 
great propriety and commendable candour, — as in certain constitutional or ac- 
quired predispositions — of which, however, we may know nothing — disturbances 
may occur, it is not out of place to refer to the practice which, under apparently 
similar circumstances, has been found most useful." 

Certain morbid states occasionally occur after etherization. These, ac- 
cording to Dr. C, are sometimes recurrences of trouble, after the imme- 



1849.] Channing's Treatise on Etherization in Childbirth. Ill 



diate effects have been suspended, or have disappeared; in other cases they 
appear to be an increase of what has attended etherization, or are dis- 
turbances produced by accidental causes acting upon a merely acquired 
predisposition. They are to be treated in the same manner as similar 
morbid conditions should be when induced by any other cause. 

Etherization has been known to diminish or suspend uterine contractions. 
In such cases Dr. C. recommends an infusion of ergot without the powder. 

Our author proceeds in the next chapter to consider the objections to 
etherization in childbirth — These are 1st. The pains of labour are not so 
severe as to authorize the use of an agent of known power to destroy 
sensibility. This objection is a trifling one. The amount of suffering in 
childbirth certainly varies very much in different cases. It is borne by 
some women without much complaint, while by others its anticipation 
even is looked to with fearful anticipation. Few, we think, will be inclined 
to deny, that a means of preventing the pains of labour, provided they 
were satisfied its use would be unattended with risk to the mother or to 
her child, is a desideratum — that the discovery of such a means will not 
prove a blessing earnestly to be desired. 

2. Etherization is not certain, and may be unsafe. This objection 
can only be answered by the results of experience. Dr. C. believes that 
these results, so far as experience of the effects of the agent up to the present 
time has gone, are in proof both of its certainty and safety. 

3. The religious objection. — This objection is an exceedingly futile one, 
and so far as it is based on Gen. iii. 16, has evidently arisen from a mis- 
conception of the text. 

4. The moral objection. — This is an equally weak objection with the 
foregoing. It is admitted that the inhalation of ether and chloroform has 
been resorted to by persons in health for the pleasurable excitement they 
produce, and has, in consequence, been the cause of the most serious 
injury. But the abuse of any agent cannot be urged as an argument against 
its legitimate use for the relief of physical suffering or the cure of disease. 
Admit its validity, and we should be forced to strike from our lists of the 
materia medica opium, wine, ardent spirits, and a number of other im- 
portant remedies, the abuse of which has been the cause of far more moral 
evil than can possibly result from the unprofessional employment of either 
ether or chloroform inhalation. 

5. It may injure the child.— This objection can be answered only by 
the lessons of experience. Dr. C.'s observations on this point will be learned 
from the following quotations: 

" Etherization, we are told, may mentally or physically affect the infant. It 
may we weakened in mind or body; and particular diseases are named, which 
may be looked for from the agency of the remedy of pain. This objection rests 
upon hypothesis alone. It has no facts for its origin, and none for its support." — 
" There is not the smallest evidence of any such injurious agency in store for the 
child bora during etherization ; and that, so far from this being the case, or is to be 
apprehended, it is notorious that children born during this state are much more 
rarely still-born, than are those born without its agency, and that they have continued 
to do perfectly well." 

Having examined, in the first six sections or chapters of the treatise, the 
leading topics connected with the subject of etherization, Dr. Channing 
presents next the histories, more or less in detail, of seventy-seven cases 
of labour in which etherization was employed. Then follow three tables 
embracing the cases communicated in answer to the author's circular, ad- 
dressed to a number of physicians in Boston and its vicinity, with the view 



112 



Reviews. 



[Jan. 



of ascertaining the extent to which etherization had been employed and 
what had been its results. The cases thus reported, with those which have 
come under his own immediate observation, amount to five hundred and 
seventy-four. The first table comprises five hundred and sixteen cases, 
in which the foetal head presented, and in which delivery was effected by 
the unaided efforts of the womb. The cases included in this table he 
considers to be those by which the propriety of etherization in childbirth 
is to be tested, inasmuch as many of them were protracted, and others of 
great difficulty. No notice is taken of the puerperal state ; because we are 
told, in all, except three of the cases, nothing untoward occurred. In the 
three exceptions, puerperal fever followed the use of chloroform. In one, 
the fever occurred thirty-six hours after delivery, when the patient was 
apparently doing perfectly well, and in immediate connection with the 
operation of a very active cathartic. In the other two cases, the fever 
occurred under circumstances which excluded the idea of any connection 
whatever between it and etherization; the disease appearing in other females 
at the same time and in the same vicinity, who had not been subjected 
during their labours to etherization. 

In this first table five instances of still-birth are noticed. 

"Of one of these, it is said, in answer to the circular: — 'one still-birth; but I 
question if effect of ether.' Concerning two, Dr. C.'s correspondent remarks: — 
' Two of the children were still-born: in one of these cases the condition of the 
child showed that it had been dead severaldays before labour commenced. In 
the other case, the labour commenced with profuse flooding, probably from a par- 
tial or entire separation of the placenta from the uterus; while the labour was not 
finished for seven or eight hours afterwards.' The circumstances of the other 
cases of still-birth, in like manner, explain its occurrence without any reference 
of it to etherization. Thus, in 516 cases of labour, embracing among them all 
the circumstances belonging to this process, except instrumental or manual aid — 
in all these cases of labour, accomplished during etherization, we have not a case 
in which the mother did not do well. Cases of still-birth are referred to; but these, 
as we have seen, had no connection with etherization." 

The second and third tables comprise fifty-one cases of instrumental, 
preternatural, and complicated labour; in twenty-seven of which Dr. C. 
was consulted, and twenty-four were communicated to him. They occur- 
red in the practice of about forty physicians in extensive practice in Boston 
and its vicinity. Dr. C. informs us that he endeavoured to collect all the 
cases of the three classes of labour, above named, which have occurred 
since the first use of etherization in that city; and though he thinks it im- 
probable that he has wholly succeeded, still he believes that he has obtained 
the greater number. An analysis of this table is given, upon which the 
author remarks as follows: — 

"This analysis gives four deaths in fifty-one labours, comprising the most dan- 
gerous complications of that process, and requiring methods of treatment in them- 
selves more or less hazardous to life. I believe, without attempting any compari- 
son here of these with like cases in number, as well as of kind, in which ether- 
ization has not been employed, that the records of medicine do not present such 
an amount of safety; so many and such perfectly successful results in operative, 
preternatural, and complicated labour, as are shown here to have followed ether- 
ization." 

The table includes twenty forceps cases; twenty cases in which cranio- 
tomy was performed; nine cases in which the upper extremity presented; 
three cases of breech presentation; one case in which the labour was com- 
plicated with accidental, and two with unavoidable hemorrhage, and two 



1849.] Channing's Treatise on Etherization in Childbirth, 113 



3 


it 


1 




2 




1 


t< 


1 


a 


1 not born. 


1 


it 


1 


a 


1 still-born. 


, 1 


a 


1 


a 


1 




2 


a 


2 


a 


2 


n 


1 


a 


1 


tt 


1 


n 


1 


u 


1 


it 


1 


a 


1 


it 


1 


a 


2 


a 


18 




15 




17 





were twin cases; in all of these the mothers recovered; in the remaining 
ten cases the labour was attended with convulsions, and in four terminated 
fatally. 

"The still-births were nineteen. Two abortions and one premature birth are 
not included. Of the nineteen, four were from craniotomy, and five in twenty 
cases of forceps delivery, comprising cases in which the labours were protracted 
three days: and others in which circumstances existed most unfavourable to fetal 
life. There were six still-births in ten cases of convulsions: for one, being an 
abortion, is excluded. This is very striking success. But the power of etheriza- 
tion was most manifested in the cases of presentation of the upper extremity. The 
tables give us nine of them, with only three still-births." 

The fourth table contains eighteen cases of instrumental, preternatural, 
and complicated labour, in which etherization was not employed. In some 
of them Dr. C. was consulted, others were communicated to him, and one 
occurred in his own practice. The following is an analysis of this table: 
Convulsions, 7 cases. 6 fatal. 6 still-born children. 

Upper extremity, 
Rupture of womb, 
Placenta praevia, 
Accidental hemorrhage, t 
Jaundice, 
Forceps, 
Anaemia, 

Labour induced, twins, 
Total, 

"Now making every allowance for unusual complications, in the instances in 
which etherization was not used, and which amount to four, (jaundice 2 : anaemia 
1 : rupture of uterus 1,) there is an unexplained balance in favour of etherization, 
of the extremest interest to both profession and public. This balance in figures 
stands thus : — 

" In regard to still-births :— 

" In eighteen cases in which etherization was not employed, there were seventeen 
still-births; or 94 45-100 per cent. 

"In fifty-one cases in which etherization was employed, there were nineteen 
still-births ; or 37 26-100 per cent. 

" Balance in favour of etherization, 57 19-100 per cent. 

" In regard to mortality : — 

" Of eighteen labours without etherization, fifteen were fatal ; or 83 33-100 per 
cent. 

" Of fifty-one with etherization, four were fatal; or 7 85-100 per cent. 
"Balance in favour of etherization, 75 48-100 per cent." 

"This volume," remarks Dr. C, "has for its object to show if etherization be 
safe in labour. It began with a distinct statement of this as its object; and this 
has not been out of view in a single step or page of its progress. It is reverted to 
here, because, in the fifty-one cases of the second and third tables, new, and as it 
seems to me, very strong evidence is furnished of the whole safety of the employ- 
ment of the remedy of pain. This consideration has a direct application to the 
fourth table. I ascribe no portion of the results of cases, as recorded in it, to the 
non-employment of. etherization; for I assume only to show, that, in the fifty-one 
parallel cases in which it was used, it did no harm. By others, different views 
may be taken of these comparative results. They may give to the fifty-one cases 
a very different and important position in our inquiry. They may consider ether- 
ization not only to have been safe here, but to have been a direct agent in the re- 
coveries which are recorded; that, not only was pain abolished, but life was pre- 
served, by its agency. Whichever view may be entertained, one inference may 
unquestionably be drawn from so many facts, — it is ; that etherization may be safely 



114 



Reviews. 



[Jan. 



employed in like cases, and that successful results maybe always looked for from 

its use." 

The volume closes with the correspondence elicited by Dr. C.'s circular; 
and, in an appendix, are given the details of several cases in which puerperal 
fever occurred after the use of chloroform ; of a case of etherization in 
nausea of early pregnancy, threatening life; of a case of etherization in 
vomiting, spasms, &c, in the sixth month of pregnancy, threatening life; 
of a case of cholera treated by etherization ; of a case of typhoid fever, 
accompanied by spasms, in which etherization was employed f of a case 
of puerperal convulsions in which chloroform was beneficially employed; 
and a number of extracts from medical journals bearing on the general 
subject of the treatise. 

In the foregoing analysis of the work of Dr. Channing we have endea- 
voured to lay before our readers a clear, full, and candid view of the cha- 
racter of the evidence adduced by the author in favour of the employment 
of etherization in childbirth, and the leading deductions drawn by him from 
his own experience on this subject, and the facts he has collected from other 
sources. 

The subject is a highly important one. The certain means for the relief 
of the pangs of parturition, is unquestionably to be hailed as a blessing 
that should not be rejected for any trivial cause or mere hypothesis. But, 
however desirable may be means for rendering childbirth painless, the simple 
fact that such means has been discovered cannot be received as any valid 
argument for its employment. The important point to be settled, as Dr. 
Channing very properly remarks, relates to its safety — can it be em- 
ployed without injury to the mother and child? The question as to its 
safety is not alone, however, whether under its use labour, in the great ma- 
jority of cases, will go on, and terminate favourably, in respect to both parent 
and offspring ; but, whether under its use risk of injury will be incurred by 
the one or the other, in any case. For, inasmuch as a remedy whose only 
object is to quell pain is not absolutely necessary in natural labour at least 
— shall it appear that in any given number of cases — be the number great 
or small — risk of injury will be incurred from the employment of ether- 
ization, unless such cases can be determined beforehand, we are not war- 
ranted in its employment in any. 

Dr. Channing, by the facts he has collected, has certainly offered a very 
respectable amount of evidence in favour of the general safety and absence 
of risk in the employment of the anaesthetic agents to quell the pains of 
labour. He is himself a zealous advocate for their use in every and all 
the circumstances under which labour may occur — and though his zeal 
has caused him, occasionally, to give undue weight, in the settlement of the 
question, to considerations resulting solely from the surprising relief from 
sufferings caused by the administration of these agents — and to ascribe to 
them an importance in obstetric practice, independent of their power of 
subduing pain — still as all his statements and reasonings are evidently the 
result of a deep and honest conviction of the safety and propriety of 
etherization in childbirth, they demand a candid and serious examination. 
His views are stated fully and freely, and from a sincere belief that they 
have a legitimate basis in numerous and well-established facts. The work 
is not perhaps written with all that care which the importance of the subject 
demanded — and although to a great extent deficient in strict logical arrange- 
ment, and abounding in repetitions and irrelevant remarks, still as present- 
ing very fairly the present state of our knowledge as to the effects of 



1849.] Charming 1 's Treatise on Etherization in Childbirth. 115 



etherization in childbirth, it will be consulted with interest by all who de- 
sire to be informed upon this question. 

So far as it goes the evidence adduced by Dr. Channing is in favour of ether- 
ization in childbirth. He has shown, at least, that no untoward results have 
arisen from its use in the hands of numerous physicians during labour; while 
no adverse experience has been communicated. But still the evidence he has 
presented is insufficient to settle definitely the question as to whether there 
may not possibly be some risk incurred from its use. Dr. Channing, it is 
true, insists upon the safety and propriety of its use in all the forms of 
labour — natural, instrumental, preternatural and complicated — and even goes 
so far as to affirm that the presence of disease of the head, brain, heart or 
lungs, in the parturient female, are not in themselves contra-indications for 
etherization. It is this ascription of properties so surprising to this agent 
—the assertion that, while it has the power to suspend sensibility and 
paralyze the muscles of animal life, it may be given with entire safety, 
whatsoever may be the age, constitution and state of health of the female 
or the nature of the labour — which has startled many cautious obstetricians, 
and deterred them from a resort to it under any circumstances whatever. 
No other active article of the materia medica is capable of being safely 
employed under so wide a range of circumstances, and it will demand 
stronger evidence than has yet been presented to prove that etherization can. 

It is urged in favour of etherization that besides suspending the pangs 
of childbirth, it facilitates the process and renders it more safe — " I firmly 
believe," says Simpson, " that the superinduction of anaesthesia in obstetric 
practice, will yet be found to diminish, and remove also, in some degree, 
the perils as well as the pains of labour," which sentiment is endorsed by 
our author, who states again and again, " that during and in consequence 
of etherization, circumstances highly favourable to safe as well as easy 
labour arise." A most surprising agent truly — it not only removes pain, 
and increases the physiological actions of the uterus, but facilitates also the 
passage of the child, and these beneficial effects, instead of being attended 
by an increased risk, on the contrary, the ordinary risks of childbirth are, 
by the magic powers of etherization, lessened if not removed. 

These exaggerated, as it seems to us, accounts of the effects of ether- 
ization will soon be corrected by the results of experience, and should 
not cause us to disregard the history of its use, and the evidence thence 
deduced in regard to its effects. 

We return our thanks to Dr. Channing for having collected much of this 
evidence ; for, adopting in part his own language, although the question 
" How generally should etherization be employed in midwifery? and what 
are the safe and proper limits of its use ?" is still an open one ; nevertheless 
" the time which has been occupied in the observation of the facts, has 
not certainly been lost time." D. F. C. 



116 



Reviews. 



[Jan. 



Art. XVIII. — Observations on the Pathology of Croup, with remarks 
on its treatment by topical medications. By Horace Green, A. M., 
M. D. &c. &c— New York: 1849. 12mo. pp. 115* 

Many of our readers will remember the author of the above treatise as 
having attempted to revive a mode of treating laryngeal phthisis which was 
employed first and then abandoned by MM. Trousseau and Belloc. This 
method consisted in the introduction of a sponge, wet with dissolved nitrate 
of silver, into the larynx. The general impunity, and in many cases the 
advantage, with which it was practised appears to have more immediately 
suggested Dr. Green's experiments with a similar method in croup. To 
any one acquainted with this fell disease, the- proposed remedy must cer- 
tainly be unattractive; yet no instinctive repugnance should be allowed to 
prevent an impartial examination of this or of any other means which 
promises to subdue, or even mitigate its terrors. In the present instance 
analogy and experience appear to favour the proposed plan, for cauter- 
ization is neither a new remedy in croup, nor one without authority to 
recommend it. Whether Dr. Green has made any real or essential change, 
and, what is of greater consequence, whether he has introduced any im- 
provement in this department of therapeutics, are questions which we 
shall endeavour to answer while passing under review the three principal 
divisions of his essay. These are 1st, the Pathology of Croup; 2d, the 
treatment of croup by applying lunar caustic to the affected membranes; 
3d, the general remedies employed to cure the disease. 

The Pathology of Croup. — At the outset the somewhat startling state- 
ment appears as a quotation from Double, that croup proves fatal in nearly 
one-half of the whole number of those who are attacked by the disease, 
(p. 2). Royer Collard (Diet, en 60 vols., art. Croup) and the authors 
of the Compendium de Medecine Pratique, quote Double as making the 
proportion of deaths one-third. We have not the original work within 
reach, and merely note the discrepancy. Whichever statement is correct, 
the opinion of Double upon the subject is of little value, for his work was 
published in 1811, and long, therefore, before the true distinction was 
made between membranous and stridulous croup. In opposition to Dr. 
Green's adopted opinion we quote that of M. Guersent, which is that 
scarcely two out of ten patients escape death, and even this, as has been 
well remarked, is too large a proportion, if hospital cases are reckoned 
alone. The truth is that to say one-half of those attacked with membran- 
ous croup recover, is almost as great an exaggeration as to assert that a 
like proportion of cases of stridulous croup perish. 

On p. 4, Dr. Green states that "the distinctive and essential charac- 
teristics of true croup consist in an inflammation of the secreting surfaces 
of the fauces, larynx, and trachea, which is always productive of a mem- 
branaceous or an albuminous exudation." Again, on p. 5: "I affirm that 
inflammation of the respiratory mucous membrane — whatever may be its 
grade — if unattended with an albuminous exudation, can no more constitute 
croup" than any disease of the lungs without tubercles can constitute 
phthisis. In these propositions all sound pathologists must concur, and 

* As the verification of dates is sometimes important, it should be known that the 
date upon the title-page is incorrect, the work having been in our possession early in 
October 1848. 



1849.] Green's Observations on the Pathology of Croup. 117 



we were therefore taken by surprise on finding " spasmodic croup" ranked 
by the author as a variety of this malady, and not as a distinct disease; as 
an affection in which spasmodic and nervous elements predominate, but in 
which, nevertheless, the albuminous secretion is effused, although more 
tardily. The remissions which take place in the early stage of spasmodic 
croup occur? says Dr. Green (p. 9), "not because there is no degree of 
inflammation present and, consequently, no obstructions from albuminous 
secretions, but for the reason that this last morbid condition is not of 
sufficient extent, at this period of the malady, to embarrass respiration." 
Again (p. 55), " patients are frequently cut off by the violence of the spasm 
before the plastic exudation has become in any degree condensed into a 
continuous membrane." 

In the preceding quotations it will be observed that albuminous exu- 
dation is first stated to be essential to constitute croup, and then it is 
assumed that in spasmodic croup (so called) a membrane indeed exists, 
although not of sufficient extent to embarrass respiration, even in fatal 
cases of this form of croup. Undoubtedly, if the latter proposition were 
proved, the existence of stridulous laryngitis (spasmodic croup) as a dis- 
tinct disease, could not be for a moment sustained. But the assumption 
is wholly unfounded and gratuitous; the only dissections we are aware of 
having been made in spasmodic croup show the absence of false mem- 
branes in the respiratory passages. (See Rilliet and Barthez, Mai. des 
JEnfans, torn. i. p. 396.) Dr. Green, it is true, quotes Guersent as having 
shown from the dissection of cases, when this " spasmodic form of croup" 
terminated fatally, that "albuminous concretions — sometimes extensive, 
but more frequently consisting of small isolated patches — are found in the 
larynx." There must be some mistake here, for we have been unable to 
find any such passage in the article from which it purports to be taken. 
On the contrary, (Diet, de Med. 2ieme ed. torn. ix. p. 357,) M. Guersent 
says expressly, " As I never saw a single person die of this disease, unless 
it was complicated, I am unable to describe the anatomical •characters of 
spurious croup, which are unknown to me." 

To strengthen his singular position still further, Dr. Green pursues: "Dr. 
Williams also affirms that ' although the albuminous effusion is generally 
thickest and most tough in sthenic cases of croup, yet it is pretty abundant 
in asthenic cases.'" The bearing of this statement upon the question it 
would be difficult to conjecture. 

It follows, therefore, that Dr. Green is entirely unwarranted by any facts 
on record, in stating that there is a membranous exudation, either more or 
less, in the "spasmodic form of croup;" and consequently, his inference 
from this statement, that the diseases commonly included under the name 
of croup form a pathological unity, falls of itself to the ground. 

Dr. Green next quotes the (we hope) well-known paper of Dr. John 
Ware on the " History and Diagnosis of Croup" but apparently for no 
other purpose than to make a forced application of a cautiously expressed 
doubt of that sound thinker and conscientious physician. In order to ac- 
complish this object, both the letter and the spirit of Dr. Ware's paper 
are misrepresented, for its whole argument goes to prove what Dr. Green 
is loth to admit, namely, that membranous croup is comparatively a rare 
disease, and one essentially distinct from other affections which it is cus- 
tomary to comprehend under the title of croup. Dr. Green informs us 
that Dr. Ware makes two distinct varieties of croup, the membranous and 
inflammatory; but this is only one-half of the truth, for Dr. Ware makes 



118 



Reviews. 



[Jan. 



four distinct varieties of croup, the membranous, inflammatory, spasmodic, 
and catarrhal. Of these the one called by him inflammatory is so named 
because it presents the characters of simple inflammation, par excellence ; 
in all the other varieties an inflammatory element is admitted, not alone, 
however, but associated with a plastic, a spasmodic, or a catarrhal element. 

Dr. Green, as we have said, erroneously states Dr. WareVvarieties of 
croup to be membranous and inflammatory merely; he then mentions that 
22 out of 131 of the cases were of membranous croup, and leaves it to be 
inferred that the remainder were " inflammatory." This is so far from 
being the case that only 18 out of the remaining 109 are classed as inflam- 
matory by Dr. Ware, leaving 91, or seven-tenths of the whole number of 
cases of " croup" for the spasmodic and catarrhal varieties whose existence 
Dr. Green does not so much as notice. 

One word more in regard to the "inflammatory" variety of Dr. Ware, 
and which he with so much justice separates from the spasmodic and ca- 
tarrhal forms; — we believe it to be simple laryngitis, on the ground of the 
symptoms ascribed to it by Dr. W., and their coincidence with those laid 
down by Rilliet and Barthez, and other accurate pathologists, as belonging 
to simple inflammation of the larynx. The dissections which Dr. Ware 
cites from Dr. Jackson in every instance prove the disease to have been 
acute simple inflammation of the mucous membrane of the larynx. That 
he should have been deceived by the symptoms is not wonderful, for, as 
the authors just named well observe, the diagnosis between severe erythe- 
matous and pseudo-membranous laryngitis is sometimes so difficult, that the 
most accomplished practitioners have been, and often will again be led into 
error. {Op. cit., t. i. p. 420.) 

Four varieties of croup, and not two, having been admitted by Dr. Ware, 
he distributes these into two great classes according to their respective 
tendencies to cure or death. The one class comprises membranous croup 
alone, because out of 22 cases seen by him in twelve and a half years (not 
twenty-five years as Dr. Green states), only three recovered; the other 
class includes all other forms of "croup," because out of 109 cases of 
them seen by him in the same time, not one died. That such a result 
should be obtained from two forms of a disease essentially the same, and 
observed during so long a period, will hardly be believed by any one who 
has not in view some other object than the simple truth. 

In establishing four varieties of croup Dr. Ware cautiously remarks that 
he does not mean to express the opinion that they constitute four distinct 
diseases, nor even " assert positively that they are not different manifesta- 
tions of the same disease." Now this remark, which, as we -shall in a 
moment show, referred principally to the three non-membranous varieties, 
Dr. Green does not scruple to quote as if applied by its author to tw r o 
forms alone, the membranous and inflammatory. To prove that we have 
■correctly apprehended Dr. Ware's intention, many passages in his essay 
might be quoted, but we select the last of his general conclusions, which 
is as follows: membranous croup " differs not in stage or degree, but in 
kind, from all the other cases which are known by the name of croup, and 
the latter have no tendency to become converted into or terminate in the 
former.' 1 '' It is clear, therefore, that Dr. Ware had no intention of attribu- 
ting to membranous croup an identity of nature with any of the other forms 
described by him. 

There is another proposition established by Dr. Ware, and which has a 
very important and interesting connection with the present subject, it is 



1849.] 



Green's Observations on the Pathology of Croup. 



119 



this: "The membranous is the only form of croup attended with any con- 
siderable danger to life." This conclusion is important; for, if it can be 
ascertained that in a given case the symptoms are not those of membran- 
ous croup, the little patient will be saved a great deal of unnecessary if not 
injurious manipulation; and if the conviction of this truth can be generally 
disseminated, and deeply impressed on the minds of physicians, it will pro- 
bably lead to a more attentive analysis of symptoms in croup-like cases, 
and confine the use of the laryngeal probang to an extremely small num- 
ber amongst them. 

It matters little whether in our theories of the nature of croup-like dis- 
eases, we regard them as degrees or forms of the same malady, or as dis- 
tinct affections ; but it matters much that in practice a class of cases in 
which false membrane is formed should be clearly distinguished from an- 
other class of cases in which false membrane is never developed. It 
matters much, nay it is of infinite moment, that the self-same treatment be 
not applied to a class of cases whose spontaneous tendency is to recovery, 
and to another class whose spontaneous tendency is with equal certainty 
to death. 

Dr. Green concludes his remarks upon diagnosis by mentioning that he 
does not intend to comprise in the one disease described by him (already, as 
we think, unduly swollen by foreign matters) that hysterical affection of 
adult age which not unfrequently assumes the character of croup, nor the 
disease of infancy known as laryngisszmus stridulus. The last term is so 
written both in the text and table of contents. He then divides croup into 
laryngeal, tracheal, and bronchial; and yet is at pains to show, although 
without any reference to the elaborate statistics of Bretonneau, Guersent, 
and Hussenot, that the essential false membrane commences primarily 
about the fauces and the upper portion of the respiratory passages and ex- 
tends universally, from above downwards. No one, we believe, ever saw 
plastic exudation confined to the trachea, and as for that which occupies 
the bronchia originally, it is pseudo-membranous bronchitis, or suffocative 
catarrh — not croup. The author's division is simply impossible. 

On p. 14, the following passage occurs: "With respect to the source 
of that peculiar exudation which is poured out upon the inflamed mucous 
surfaces in croup, I have before expressed the opinion that it is an effusion 
from the diseased follicles of the tonsils, larynx, and trachea." To sus- 
tain this opinion, which Dr. Green appears to imagine singular and original, 
he favours the reader with an anatomical account of the mucous follicles, 
informs him that according to late microscopic observations, it consists " of 
water with a viscid substance, which is termed mucus," and thinks it ne- 
cessary to quote Haase in order to show that filaments of the membrane dip 
into the orifices of the " municiperous" [muciparous] glands. Just sixty 
years ago a physician of New York, the fidelity and candour of whose 
descriptions are above praise, Dr. Samuel Bard, wrote as follows: "The 
affection of the mucous glands must be considered as the proximate cause 
of this disease ;" and again, . . . " Miasmata, which have a singular tend- 
ency to attack the throat and trachea, affecting the mucous glands of these 
parts in such a way as to occasion them to secrete their natural mucus in 
greater quantity .... which, when secreted, is either really of a tougher 
or more viscid consistence than natural, or is disposed to become so from 
rest and stagnation." (On Angina Suffocativa. Trans, of A. P. S., vol. 
i. p. 394-397.) 

On p. 16, Dr. Green refers to his former work on "Bronchitis," 



120 



Reviews. 



[Jan. 



and presses anew the opinion there insisted upon, that " the pathologi- 
cal relations which exist between the throat and the respiratory tubes are 
not justly regarded by medical writers." In this, also, the author has no 
claim to having advanced a novel idea ; as will appear further on, previous 
writers have recognized the frequent dependence of laryngeal upon pha- 
ryngeal conditions, even so far as to explain by its means the success of 
their treatment applied to the latter. 

Cauterization in Croup. — At the commencement of Chapter II., the 
author states the occasion of his adopting this method. " Guided," he 
says, " by this view of the seat, progress, and pathology of croup, and an 
extensive experience in the topical treatment of other diseases of the air 
passages, I adopted the determination several years ago to make the attempt 
in croup, whenever opportunity should offer, to arrest the exudatory in- 
flammation, and thus prevent the formation of a false membrane ; or when 
formed, to promote its separation and consequent expulsion by the employ- 
ment of topical applications to the mucous surfaces of the fauces, larynx, 
and trachea." In no part of this passage is the least hint offered of other 
persons having employed a similar mode of treatment; but it is made to 
appear as the result of the author's own reasoning and experience. Never- 
theless, Dr. Green ought not to be surprised if physicians choose to attri- 
bute his experiments to the numerous examples which others had set, 
rather than to the reflections which he assigns as their source. In a sub- 
sequent chapter, indeed, (Ch. V.) he admits that the topical application 
of a solution of the nitrate of silver in membranous croup has been re- 
commended by Bretonneau, Dupuytren, Guersent, MM. Trousseau, Guiet, 
Bouchut, and other French practitioners, an array of precedents, one 
would suppose, sufficient to absolve him from the labour of inventing the 
method anew, and, above all, to prevent his putting forward any claim to 
originality in the invention, so far as the application of lunar caustic to the 
fauces and larynx is concerned. We shall show that he was anticipated 
even in the direct introduction of this agent into the cavity of the larynx. 

But Dr. Green thinks that all of the practitioners above mentioned fell 
short of obtaining the greatest good, because they applied the caustic solu- 
tion to the fauces and superior opening of the larynx, instead of carrying 
it directly into the latter. Moreover, he strangely objects to the solution 
used by Bretonneau, as too weak, although in the proportion used by him- 
self, 5j to ^j ; and to the solution employed by M. Bouchut, (3iiss to ^j) 
as too strong, although he elsewhere avers (p. 50, and p. 82) that children 
with croup are less irritated by the argentine solution, than are adults with 
chronic disease of the larynx. The proportions recommended by Dr. 
Green are two scruples or a drachm of the crystallized nitrate silver to an 
ounce of water, but he offers no proof of the dangers which the stronger 
solution may give rise to. 

The earliest record of the employment of lunar caustic in croup, is 
probably that contained in the Ed. Med. and Surg. Journ., April, 1825. 
In a paper "On the Symptoms and Cure of Croup," Mr. Mackenzie, of 
Glasgow, reports a means of treating the disease which, he says, "has 
been repeatedly successful in my own hands, as well as in the hands of 
those from whom I first received my information of its utility." Who 
these persons were he does not state. Mr. Mackenzie employed a solu- 
tion of a scruple to the ounce, which he conveyed by means of a large 
camel's hair pencil to all parts of the fauces and pharynx within reach. 
" This remedy," he remarks, " uniformly alleviates the symptoms of croup, 



1849.] Green's Observations on the Pathology of Croup. 121 



such as the difficult respiration, the barking cough, and the peculiar anxiety 
of the patient. It has evidently such an effect upon the diseased surfaces, 
both those which it actually touches, and those which are continuous, as to 
induce them to throw off the false membrane by which they are covered, 
and it appears also to prevent the further progress of the exudation." 

In the years 1826-27, Dr. Lewis Belden, of New York, treated ten 
cases of cynanche maligna successfully, employing the solid nitrate of 
silver, and a saturated solution of this salt, topically. In two of the cases 
the membranes appear to have extended into the larynx. (Med. Recorder, 
vol. xiii. p. 125.) 

The editor of* the Med.-Chirurg. Review, July 1828, p. 459, states that 
a French physician, M. Gerouard, lately transmitted a memoir to the 
Society of Medicine in which he relates many cases of the success of nitrate 
of silver in the treatment of plastic inflammation of the larynx and trachea. 
" He recommends the caustic to be applied not only to the fauces, nares, 
and parts adjacent, but to be introduced into the larynx, where the inflam- 
mation has affected that part. M. Gerouard frequently employs the nitrate 
in substance carefully fixed in a silver tube, straight or crooked. He ob- 
serves, that to cause the false membranes to be detached from the larynx or 
trachea, it is not always necessary that the caustic should enter these con- 
duits. ' It is sufficient in many cases to touch the superior aperture. I have 
seen patients eject membranous tubes, of some inches in length, the day 
after the rima glottidis was touched with caustic' " The editor subjoins 
a comment which, although unconnected with the present subject, has a 
direct bearing upon Dr. Green's claims in another department of laryngeal 
cauterization, and we, therefore, quote it. " We wish to draw the attention 
of the profession to the employment of this topical application in laryngeal 
affections simulating phthisis. We have seen some cases recently where 
chronic coughs accompanied by muco-purulent expectoration, that had 
harassed patients for years, and baffled all their physicians, give way in a 
very rapid manner, to a few applications of lunar caustic on the sponge of 
a common probang. These hints may prove useful to many of our 
brethren. The state of the fauces should be carefully examined in all 
cases of chronic cough ; and the epiglottis may be often seen by pressing 
down the tongue. That part, and even the rima glottidis may always be 
examined with the finger." In these two quotations, dating twenty years 
back, we have a summary, by anticipation, of all that is useful in recent 
treatises upon the value of lunar caustic in acute and chronic inflamma- 
tions of the larynx. But we return to the precedents for its use in croup. 

In 1837, M. Hatin (Bull, de Therap., t. xiii. p. 263) recorded his suc- 
cess in treating four cases of membranous croup by the method of M. Pe- 
ronneau, cauterization of the pharynx with the solid nitrate. "I had ima- 
gined," he remarks, " that to succeed, the caustic must enter the larynx . . 
yet without this, croup is cured." After conceding that this method is 
chiefly applicable to the commencement of the disease, he remarks that 
by passing the caustic through the larynx, there would be a hope of de- 
stroying false membranes even in the trachea itself, and that the operation 
ought certainly to be tried. 

Bretonneau, in 1839, published in the Gazette Medicate, a case of 
secondary croup occurring in an adult, and which he successfuly treated by 
means of a solution of nitrate of silver containing two drachms and a half 
of the salt to an ounce of water. We presume that Dr. Green's objection 
to the feebleness of Bretonneau's solution will not apply to that used by 
him in the present case, and which was introduced into the larynx by 



122 



Reviews, 



[Jan. 



pressing the sponge containing it upon the opening of this organ, and be- 
hind the epiglottis. Our author is quite ruffled at rinding in a description 
of this operation by Berton, that the epiglottis is directed to be raised, 
(soulevee), and adds in a note, (p. 77,) "If the French anatomists will ac- 
quaint themselves with the position of the living epiglottis when in situ, 
they will find that this cartilage is always raised, except at the moment of 
deglutition." It would be somewhat difficult for these persons who are so 
sharply twitted by Dr. Green, to examine the living epiglottis except in 
situ ; after all, they perhaps do not need the lesson, since strange as it 
may appear, Dr. Green's description of the epiglottis is almost a literal 
translation of Cruveilhier's " sa direction est verticale, excepte au moment 
de la deglutition.^ These unskilled anatomists, too, might ask Dr. Green 
whether the contact of a probang with the fauces does not excite an act 
of deglutition, and require the epiglottis to be raised, or drawn forward, in 
order that the instrument may reach or enter the opening of the larynx ? 

Dr. Gibbes of Columbia, S. G., has reported a case of secondary croup 
in a child, (Jim. Journ. of Med. Sci., April, 1842,) in which the first im- 
provement and ultimate cure were clearly due to the employment of a 
saturated solution of nitrate of silver applied freely and repeatedly to the 
whole extent of the fauces and pharynx. 

These citations, which might be multiplied by a reference to the writ- 
ings of French physicians named by Dr. Green, have been selected be- 
cause they all belong to a date anterior to that when, as the author states, 
he first took up the subject, and several of them to a date earlier even than 
the publication of Bretonneau's treatise. They prove beyond all question, 
1st. That lunar caustic was long ago introduced into the larynx, for the cure 
of croup, in the solid as well as in the liquid form ; 2d. That this remedy 
effected cures even when it was applied to the fauces and pharynx alone ; 
3d. That the physicians who employed it expressly recognized the power 
of the caustic to cause a separation and rejection of the laryngeal membrane, 
although applied to the adjacent parts alone ; and, in a word, that the cure 
of croup by nitrate of silver applied topically was shown to be possible 
by competent and independent observers before the first trial made with this 
agent by Dr. Green. What advance, then, has the physician just named 
made beyond established results ? Can he claim to have invented cauteriza- 
tion in croup ? Certainly not. Can he claim to have first introduced caustic 
into the larynx for this disease ? We presume not. Has he invented any 
new instrument for performing the operation? None. The bend of the 
whalebone, the size of the sponge, the manipulation of the instrument, 
were all described by M. Trousseau ten or twelve years ago. What then 
are his claims ? Simply to have first introduced a sponge, as well as 
the caustic solution, into the larynx. How far this is an improvement 
worthy of being adopted, or how far it is an innovation deserving of blame, 
is the question, the whole and the only question of general medical inte- 
rest presented by Dr. Green's publication. We shall examine it briefly. 

Let us first inquire what facts are adduced by the author in support of 
his method. His book contains an account of fourteen cases of " croup" 
in children, ten of which were seen by himself; the remainder are re- 
ported, one by Dr. Bryan, two by Dr. Blakeman, and one by Dr. C. E. 
Ware. Of these, cases 1, 2, 3, 4, 7, 9, 10, 13 and 14, may be admitted 
as examples of true croup, on the strength of the statement that in all of 
them there was a plastic exudation upon the fauces, or that there was false 
membrane rejected by coughing or vomiting, or else found adhering to the 



1849.] Green's Observations on the Pathology of Croup. 123 



probang. Yet, with the exception of Dr. Ware's case, there is not one of 
this series described with sufficient minuteness ; in all of them a sort of 
summary is given which leaves untold what it would be of greatest interest 
to learn, the influence of the treatment upon the individual symptoms, and 
the progressive amendment of these latter up to the period of complete re- 
covery. It is not enough to know that a patient ejected what appeared to 
be false membrane, after cauterization, and then "rapidly recovered," for 
there is such a thing possible as to mistake mucus coagulated by lunar caus- 
tic for false membrane; and there is a wide difference between the rapid 
recoveries which took place in all but one of Dr. Green's successful cases 
and that slow restoration which was observed by Dr. C. E. Ware under iden- 
tical treatment, and has been noticed by other physicians in croup cured by 
all other methods. These facts tend to inspire doubt. In the first two cases 
the caustic was not used until a very advanced stage of the disease, and the 
patients died. In the 3d, the patient " appeared quite cheerful, and apparent- 
ly almost free from disease," about thirty-six hours after the croupal symp- 
toms set in. In case IV., after about an equal lapse of time, "no further 
medication was needed." In case VII. the patient had bronchial inflam- 
mation (pseudo-membranous?) as well as croup, had been sick "for nearly 
a week, and was then dangerously ill," yet in from twelve to eighteen 
hours after the first cauterization she "recovered rapidly." Case IX. is 
much less imperfect in its details; the patient's throat and larynx were 
cauterized from the onset of the croupal symptoms; but not until nine 
hours afterwards, during which time the caustic had been applied four 
times, was there any decided relief, and it was immediately followed by 
plastic bronchitis. About eighteen hours afterwards hydrocyanic acid was 
administered, under which the symptoms abated, cauterization was re- 
newed, false membrane was ejected, and by the end of twelve hours more 
the "croupal symptoms had nearly disappeared." The patient, however, 
was only "gradually restored to health and strength." In Dr. Bryan's 
case the patient was struggling in a paroxysm of croup, at seven o'clock of 
one evening, and by six o'clock of the next evtning but one was " sitting 
up on its mother's lap amusing itself with toys." Dr. Ware did not see 
the subject of his case until the proper croupal symptoms, which had been 
coming on for a week previously, had been developed for twenty-four 
hours, nor did he use the caustic until twelve hours later. The improve- 
ment was marked at first, and the breathing continued very laborious ; but 
a slight amendment took place from day to day, and not until a week from 
the first cauterization could the patient speak a loud word. 

In all such of the above successful cases as were uncomplicated with 
bronchitis, except the last, the rapidity of the cure is surprising: the slow- 
ness of the recovery in Dr. Ware's case, which was not complicated, is in 
striking contrast with it, and resembles the course of the disease in those 
treated by Dr. Clark, and reported elsewhere in the present number of this 
Journal, (pp. 26, 27.) This may perhaps be owing to the circumstance of 
Dr. Green's greater familiarity with the use of the probang, and the more 
complete evacuation which he effected by its means. If so, it is probable 
that dexterity in employing this instrument may be a very important ele- 
ment of its success, and if such be the case, few practitioners will be com- 
petent to its use, because of the rare occurrence of cases requiring it. It 
cannot be denied that in all of the cases enumerated in the above summary 
a very decided improvement took place after each operation, and even in 
those which ultimately proved fatal. How much of this was due to the 



124 



Reviews. 



[Jan. 



caustic solution, and how much to the mechanical action of the sponge ? 
According to the writers already quoted, or alluded to, as having used lunar 
caustic in croup, it procured immediate and marked relief to the symptoms 
whenever applied to the fauces or instilled into the larynx. Is it then neces- 
sary to do more ? Lest the statements of the authors in question should be 
doubted, we call upon Dr. Green himself to answer the question, which 
he does in the following words : " Not unfrequently, if topical measures are 
employed at the very onset of the disease, and before the exudative in- 
flammation has extended much into the larynx, the affection may be 
arrested by one or two applications of the caustic solution to the fauces, 
and the opening of the glottis, without ever passing the instrument upon 
the mucous surfaces of the larynx." (p. 84.) A case is given in illustra- 
tion. Here then we have the admission by Dr. Green that probing the 
larynx is not unfrequently needless in the first stage. We have also the 
assurance by others of success without it at various stages. We might 
fairly conclude that the operation ought, therefore, if adopted at all, to be 
resorted to in exceptional cases only. But it will doubtless be objected that 
the cauterization must be more effectual according to Dr. Green's method, 
because more direct, and that it oug'ht, on that account, to be preferred. 
This conclusion is perhaps not thoroughly demonstrated, and Dr. Green, 
himself, affords the means of showing that it is not. On p. 49-50 he 
informs us that patients treated by him for chronic laryngeal disease " have 
felt the fluid distinctly extending down the bronchial tubes." On p. 51, he 
recommends that in croup when the plastic exudation has extended to 
the bronchi, " a still more free use of the solution should be employed, 
in order that some part of that fluid may find its way over the diseased 
mucous surface of the lesser branches of the air tubes." Hence, if in 
any manner the fluid can be introduced into the larynx, there is nothing 
to prevent its distribution, particularly as we are told (p. 101) "it has 
been shown repeatedly" that within the membrane a space is left for a 
current of air sufficient to support life; and (p. 114) that "three-eighths 
of the aerial canal are always open." If these things are so, a fluid ex- 
pressed into the larynx at its superior opening must have quite as extensive 
a distribution, as if it were squeezed from a sponge within the larynx, be- 
sides which, a much greater quantity of fluid can be introduced by the 
former than by the latter means. Dr. Green's own statements, therefore, 
in regard to the dispersion of the caustic fluid and the physical condition 
of the air-passages, corroborate entirely the conclusion drawn from expe- 
rience, that, so far as effectual cauterization is concerned, the probang 
need not enter the larynx at all. 

It follows, from the foregoing argument, that if Dr. Green's method have 
any superiority over those before employed, it is owing altogether to the 
mechanical action of the probang in detaching and removing the exuda- 
tion. No sufficient number of cases has yet been collected, to place its 
value above or below that of other methods; but, we are quite willing to 
concede in advance its possession of a real merit, and that upon the ground, 
not only of the fifteen or twenty cases in which the probang has been used 
along with a caustic solution, but of one also in which this instrument 
was used alone, and with a mechanical purpose ; for, although the asser- 
tion may seem bold, Dr. Green was not the first to introduce this 
instrument into the larynx, for the relief of croup. In the Diet, de 
Medecine, (2eme id., Art. Croup, p. 376,) Guersent relates that, when 
the son of Napoleon's Mameluke was ill with croup, Dupnytren " at- 



1849.] Green's Observations on the Pathology of Croup. 125 



tempted to detach the false membranes of the larynx, and extract them, 
by swabbing out the interior of this conduit by means of a sponge affixed 
to a whalebone handle. With difficulty he succeeded in withdrawing some 
fragments of membrane, and the operation was followed by a temporary 
calm. The child, however, died, and it was then found that the exudation 
extended into the bronchia." Of this operation Guersent remarks, that 
" there is but little chance of its success, unless the false membranes are 
confined to the larynx, which is the least frequent case. In most cases, 
they extend into the trachea, and since it is impossible to determine how 
far they extend, there is always a risk, that by introducing a sponge into 
the larynx, the membranes may be thrust back into the bronchia, and sud- 
den death by asphyxia produced." 

The concluding portion of Guersent's criticism seems incontrovertible; 
for it is founded upon the evidence of Pathological Anatomy. If the 
mischief he points out has not yet occurred in practice, its occurrence in 
some future cases appears to be so certain, that, in the present state of 
the question, nothing but ignorance of the risk can excuse, or the danger 
of the patient's immediate death from the disease can warrant, its being 
incurred at any time after the full development of false membranes in 
the larynx is indicated by the symptoms. We may be told that no evil 
consequences have as yet followed the introduction of the probang into the 
larynx, but that, on the contrary, relief has ensued from the operation even 
when there was every reason to believe that the exudation extended far 
below the larynx. Granting this to be so, and granting also what may be 
the reason of this result, that the cough excited by the operation may over- 
come the packing of the membranes, we confess that we are timid enough, 
where human life is concerned, to shrink from an act that may be fre- 
quently repeated with impunity, but yet is in its nature dangerous, and 
nearly always unnecessary. The real practical merit of the operation must, 
we conceive, be displayed, if at all, when the exudation is confined to the 
larynx alone. Here, its capacity for mischief is trifling, and it may possi- 
bly hasten the cure by tearing away the fibrinous obstruction. Yet, every 
consideration proves that the operation is in this case unnecessary, because 
the end in view is obtained, by instilling a caustic solution through the 
glottis, and the analogy of diphtheritic angina indicates, that the forcible 
removal of a plastic exudation, does not prevent its renewal. The essen- 
tial part of the curative action is performed by the caustic, and it matters 
little how that is introduced, so that the patient be not exposed to an addi- 
tional risk. "We conclude, then, that the merit of Dr. Green's operation 
is not sufficient to counterbalance its dangers in many cases, and its Heed- 
lessness in the rest. The latter quality will be placed in much stronger 
relief, by a study of the general remedies for croup. 

In the above analysis of cases, the 5th, 6th, and 8th of Dr. Green, 
and the two of Dr. Blakeman, are omitted. Of the 5th, no details what- 
ever are given; in the 6th, a fatal case, the symptoms were less those of 
croup than of pseudo-membranous bronchitis ; the remaining three, were 
clearly cases of stridulous laryngitis, in which, however, cauterization 
was performed — and of course, successfully. 

We have only room to allude to a short chapter on the croup in adults. 
It contains a remarkable case. The patient, a pregnant female, was 
attacked with diphtheritic angina and secondary croup, after the measles. 
When at the worst, Dr. Green was called in. He employed repeated 
No. XXXIII.— Jan., 1849. 9 



126 



Reviews. 



cauterizations for three successive days, beginning with a solution of 45 
grains to the ounce of water, and increasing the proportion of the salt to 
60 and then to 80 grains. On the last day he "passed the sponge along 
the whole length of the trachea.''' The patient recovered perfectly. 

General Remedies. — The prominence given, by Dr. Green, to the 
topical treatment of croup, and the greatly exaggerated value, as we believe 
it to be, which he attaches to this treatment, will naturally mislead many 
readers, and induce them to neglect other methods which experience has 
tested, and sound reason approved. In this they would, however, be 
going beyond the example of Dr. Green himself, for he declares that he 
would not have the topical medication " preclude the employment of 
appropriate general remedies in the treatment of membranous croup." We 
entreat our readers to be, at the very least, as well disposed as the author 
to employ general remedies ; for an examination of the subject cannot fail 
to convince them, that to neglect the systematic employment of emetics and 
mercurials in true croup, is to risk if not to sacrifice, the patient's life. Dr. 
Green advocates the use of both of these remedies, but, as we conceive, 
he reverses their value as compared with that of the topical treatment, 
for he appears to think them subordinate instead of capital, and, we had 
almost said, essential. He devotes most of his remarks on emetics to 
denouncing antimonials, except in the first stage of croup; a needless 
labour, surely, for we are greatly mistaken if the best practitioners are 
not agreed to employ those emetics which vomit most actively and 
depress the least, as ipecacuanha, alum, the sulphate of copper, and the 
sulphate of zinc. The last, Dr. Green prefers associated with ipecac, 
and does not allude to either of the remaining mineral emetics, although 
so extensively and successfully used. Sulphate of copper is commonly 
employed in Germany against croup. M. Berlinguier published (Annales 
de Therap., vol. iv. p. 150) six cases of cure in which false membranes 
were ejected, and alludes to twelve more of like result. He prescribed 
from two to four grains of sulphate of copper at a dose. Schwase, Serlo- 
de-Crossen, and Godefroi, report a similar success with the same medi- 
cine. [Art. Cit.) Dr. Francis of New York, records three cases of cure 
from the sulphates of copper and zinc. (Hosack's Essays.) Forget 
relates a strongly marked case (Bull, de Therap., xxviii. 161) of cure 
by ipecacuanha. This writer, it may be stated, was very incredulous of 
the curability of membranous croup. " There are not a few physicians," 
he says, " who naively imagine that every affection of the larynx is more 
or less croupal, without counting those practitioners who speculate upon the 
credulity and the apprehensions of the vulgar." Their croups, he thinks, 
are for the most part, cases of simple, or of stridulous, laryngitis. Nonat 
[Op. cit., xxvi. 15) relates three cases of unquestionable croup cured by 
mercurials and antimonial emetics ; in one, cauterization was also used. 
Dr. J. F. Meigs (see this Journal, April 1847; and "Diseases of Chil- 
dren") has given a most satisfactory account of thecases which he success- 
fully treated, by emetics of alum and mercurials combined. Even while 
we are writing, five more cases present themselves. They occurred, too, 
in the Children's Hospital of Paris, and were treated by pharyngeal cau- 
terization, mercurials, and emetics. (MM. Cceurderoi et See, Rev. Med., 
Fev. 1848.) In one word, if all the cases of true membranous croup, which 
have resulted in cure, were collected and analyzed, it would be found that 
emetics formed the essential ingredient of their treatment, although several 
other agents may subordinately have favoured the action of these remedies. 



1849.] Green's Observations on the Pathology of Croup. 127 



Of the important adjuvants to emetic medicines in this disease, mercury- 
is certainly the chief. Dr. Green gives too much prominence to Dr. 
Rush's share in its introduction into the treatment of croup. This honour 
belongs first, to Dr.' Douglass of Boston, and then to Dr. Bard of New 
York, who considered " mercury the basis of the cure." The author 
testifies briefly, but pointedly, to its value, in common with Ryland, 
(whom he chiefly quotes, here as elsewhere,) and all physicians of 
experience and skill, who have placed their opinions upon record. Dr. 
Green agrees equally with them, in regarding depletion as of little value 
in the treatment of croup, except in the first stage of the disease, and 
when vascular excitement is excessive. After Ryland, he condemns 
tracheotomy altogether, because it is not warranted before other measures 
are employed, nor likely to succeed, when they have failed. This con- 
demnation is not warranted by the results of tracheotomy ; the operation 
has resulted in the cure of one-third of the patients on whom it was 
performed, some of whom were certainly past all hope from any of the 
usual remedies. An example of such success is presented by Dr. Meigs' 
case, reported to the College of Physicians of Philadelphia, and contained 
in the number of this Journal for October last. How far the introduc- 
tion of the probang may render tracheotomy superfluous in desperate 
cases, does not yet appear ; Dr. Green's work contains no evidence to 
warrant a belief in its becoming a substitute for the knife, in such unpro- 
mising conditions as those in which the knife has hitherto succeeded. 

We have been led, by the importance and interest of the subject, to a 
more extended comment than was at first proposed. The necessity of 
canvassing the claims of Dr. Green and of estimating the merits of his 
process, was inconsistent with a briefer notice. If the method is good, it 
should be fully known ; if bad, it should be condemned, but upon ample 
examination alone. A method, in favour of which the professed inventor 
furnishes nearly all the evidence, needs to be closely scanned, and its value 
must be in part deduced from the manner in which the evidence is given. 
For we have not yet learned to believe, that candid and rational men 
support a good cause by sophistry and mis-statement, or, that any measure 
advocated by such means, can be all that its partisans maintain it. Our 
estimate of Dr. Green's work will have been gathered in the course of 
this notice. It displays an imperfect acquaintance with the pathology of 
croup, and the history of cauterization, in this disease, which is unpardon- 
able in one who must be presumed to write for the instruction of others. 
Its representations of several authors whom it professes to quote, are pal- 
pably unwarranted by the text, and therefore unworthy of any educated 
and candid physician. By keeping out of sight the results and the methods 
before employed, it leads the reader to attribute to its author a degree of 
originality and invention to which he has not the shadow of a claim. The 
reports of the cases it contains are so meagre and bald, as to inspire doubts 
respecting them, which the lack of candour before alluded to is not adapted 
to dispel. Even when accredited for what they profess to be, they fail to 
establish the superiority of the treatment they are intended to illustrate. 
Finally, the portion of the work which treats of general remedies, is a 
totally inadequate, and an unfair representation of their value in the cure 
of croup ; and, taken together with the preceding portions, gives the whole 
an appearance of having been -written for the purpose of exalting the 
author's speciality above all that reason and experience have established 
in regard to the nature and treatment of croup. A. S. 



128 



Reviews. 



[Jan. 



Art. XIX. — Boa Vista Fever. — Report of Gilbert Kixg, M.D., In- 
spector of Hospitals, ordered to be printed by the House of Commons, 
March ioth, 1848. London, 1848: folio, pp. 16. Remarks of J. O. 
McWilliam, M.D., on the Report of Dr. King. London, 1848 : folio, 
pp. 15.] 

In the number of this Journal for October 1847, will be found an analy- 
sis of the original report of Dr. McWilliam, in reference to the introduc- 
tion and spread of fever, in the Island of Boa Vista, towards the close of 
the summer of 1845. By that report, if the facts adduced by the author 
are accurately stated, it is shown, very conclusively, that the fever in ques- 
tion was introduced by the sick landed from on board the steam vessel 
Eclair, and was subsequently communicated by contagion to persons re- 
siding upon the island. 

Under instructions from the Director-General of the medical department 
of the British Navy, Dr. King visited Boa Vista in December 1845, for 
the purpose of investigating more fully the circumstances connected with 
the origin, progress, and character of the fever which forms the subject 
of Dr. Mc William's report. The result of this investigation is presented 
in the document now before us. Dr. King's conclusions in regard to the 
origin and spread of the Boa Vista fever are, however, in direct opposition to 
those of Dr. McWilliam. He denies that the disease was introduced by 
the sick landed from on board the Eclair, or that it was communicated 
subsequently by contagion ; but maintains that it was strictly an endemic 
disease, originating from morbific causes existing upon the island. 

It is admitted that there was no disease prevailing at Boa Vista or the 
other Cape de Verd islands previously to the arrival of the Eclair with a 
sick crew in August 1845. It was important, therefore, to ascertain 
whether the fever which subsequently made its appearance was identical or 
not with that with which the men from on board the vessel were affected. 
Dr. King, therefore, immediately on his arrival at Boa Vista, on the 23d of 
December, proceeded to investigate the character of the prevailing disease. 
He did not, however, see more than fourteen or fifteen cases in all, which 
were the whole that occurred during his sojourn there of six weeks. 
He admits, consequently, that the opportunities which were afforded him 
of judging of the nature of the fever from personal observation were very 
limited, and further, that none of the patients he saw had the pathognomo- 
nic symptoms of yellow skin, or black vomit. Nevertheless, from the 
general symptoms of these cases ; from the admission of Senor Laoa, a very 
intelligent surgeon of the Portuguese navy, that the patients that Dr. K. visited 
in company with him were the subjects of yellow fever, and from the testi- 
mony of all he conversed with or examined respecting the symptoms by 
which the disease was characterized throughout its course, Dr. K. is de- 
cidedly of opinion that the fever which prevailed upon the island was 
identical with that which existed on board the Eclair. Dr. Almeida, a 
Portuguese physician of Porto Sal Rev, Dr. King informs us, considered the 
fever prevailing at Boa Vista to have been an aggravated type of the bilious 
remittent. 

In regard to the question of the importation of fever by the steam vessel 
Eclair, Dr. King makes the following statements. 

The whole of the persons, chiefly coloured, who were employed on board 



1849.] 



King on Boa Vista Fever. 



129 



the vessel or at the island in cleaning the hold or in coaling or watering the 
ship, were subsequently affected with a fever similar to that which prevailed 
among the crew, but generally, of a milder character, though evidently 
identical in nature. It does not, however, appear at all probable to Dr. K., 
that, except in one instance, the fever was contracted by these labourers 
even from the malaria which certainly existed on board of the vessel. 
Still more improbable does he consider the supposed origin of the disease 
from a specific contagion emanating from the bodies of the sick, inasmuch 
as he is fully persuaded that the labourers were not exposed to such con- 
tagion, even had it existed ; and again, because it is not reasonable to sup- 
pose that these labourers, had they been exposed to a specific contagion 
at its source, where it might be considered to exist in its highest degree of 
concentration, would have been infected with only a mild form of the dis- 
ease, and this at a considerable period after exposure, and that their families 
should have escaped the infection for even a much longer period. That, in 
some of the fatal cases, the yellow skin, black vomit and other malignant 
symptoms did actually appear, Dr. K. has no reason to doubt. But that 
five-sixths of this number should have recovered from that all but hopeless 
stage of the disease is to him quite incredible ; he is inclined to suspect 
that such statements were made partly .from interested motives, as it was 
fully expected that the British government was about to make a pecuniary 
compensation for the sufferings of those who had been attacked by a strange 
and pestilential disease, introduced by an English frigate. 

Did the disease, it is asked, become manifest in any of the labourers, ex- 
cepting one, within a sufficiently brief space of time to lead necessarily to 
the conclusion that it was derived from the sick of the Eclair? It is not 
generally supposed that the period of incubation in malignant fevers ex- 
ceeds ten or twelve days, and the Academy of Science at Paris has even 
limited the incubation of the plague itself to one week. Now the few, com- 
paratively speaking, of the labourers who were first attacked with the fever 
did not sicken until between the middle and the end of October, one month 
at least after the Eclair left Boa Vista, on the 13th of September. A 
greater number were taken ill in November, when the fever was common 
everywhere; but the majority of the sixty-three persons who were em- 
ployed about or on board the ship, or at the island, did not become affected 
w r ith the disease until December 1845, and January, February or as late as 
August and September of the following year. And when we consider the 
fatal cases, it becomes, according to Dr. K., still more apparent that the 
disease was not propagated by contagion, because six weeks had elapsed 
before the first man who died was attacked with the disease ; the next four 
contracted the fever in November, or two months after exposure to the 
supposed specific contagion ; five of the ten labourers who died had no 
symptoms of illness until December, or three months after the departure of 
the Eclair; and although it may be conceded that the disease in these men 
manifested every feature of the true yellow fever, yet no other case in their 
families terminated fatally. 

According to the statements made by the man first attacked, and whom 
Dr. K. admits may possibly have contracted his disease from the malaria 
on board the ship, 

'•'He was employed two days on board the Eclair: the ship sailed from Boa- 
Yista on the 13th September, and he was attacked with fever on the evening of 
the following day, at a dance in Moradinha, in the district of Rabil. The disease 
was very mild, and lasted only a few days; about a month afterwards, however, 



130 



Reviews. 



his three children caught the fever, and they all died; and in the succeeding month 
(November), his wife was laid up with the same disease, and died also. They 
had not in their illness, nor indeed had the great majority of the inhabitants, the 
benefit of either medicino or medical advice. It is not unlikely,' 7 Dr. King re- 
marks, u that the above facts may be considered by some as illustrative of the ope- 
ration of a specific contagion, but. for my own part, I have yet to learn when and 
where the man himself was ever within the sphere of its influence; and as the 
same fever commenced in some of the most remote villages at the end of October, 
shortly after this man's children died in Rabil, and as his wife was not attacked 
until about the middle of November, when the disease was general throughout 
the island, I can perceive no just ground for referring the origin of the fever from 
which this individual and his family suffered, and which subsequently prevailed 
on shore, to the Eclair, or for admitting its contagious property. But if this man, 
who was employed only two days, carried the fever to Rabil on the 14th Septem- 
ber, it is rather inexplicable that more than fifty men, nearly all of them married, 
who were more exposed to the presumed specific contagion, from a longer service 
in the ship, in the boats, and on the island, and who returned to their own houses 
in the same villages every evening, had no symptoms of disease themselves, or 
their families, until October, when the rainy or sickly season had commenced." 

Dr. King states, in reference to the sickness of the man above alluded 
to, and his family, that if there is one spot more than another in the whole 
island, where, from its physical peculiarities, endemic fever might be ex- 
pected to begin first, and end last, that locality is Moradinha and the vil- 
lages in its vicinity, in one of which he resided. 

Of the three soldiers, who constituted the guard at the fort when the 
Eclair's people left the island, two, a corporal and a private, were attacked 
with a fever resembling that which prevailed on board the ship, and died, 
the one on the 21st and the other on the 22d of September, after an illness 
of five or six days. Both of these men were pre-eminently exposed to 
the attack of endemic fever, being Europeans, who had but lately arrived 
in the colony. Neither were ever on board the frigate, and Dr. K. has 
no reason for believing that either of them had been permitted to enter the 
sick apartments at the fort. The surviving soldier, and another who 
joined him at the fort, communicated the disease to a female and the inha- 
bitants of Porto Sal Rey. 

The soldier informed Dr. K. that he was attacked with slight fever some 
days after his comrades died at the fort: on that account he, and another 
who had been sent to assist him in attending the sick, were removed 
to Porto Sal Rey, and restricted to the occupation of a small hut at the 
northern end of the town. They remained here seventeen days without 
having communicated with any one. The one who was sick soon reco- 
vered, while the other continued in good health ; and their services being 
now required in the barracks, where the fever had already commenced, 
all restraint was removed, and they returned to their military duties. After 
a residence of eight days in barracks, the companion of the first soldier 
was seized with fever, about the end of October ; in his case, also, the 
disease terminated favourably. If, remarks Dr. K., the soldiers were 
visited by the female, who was the first victim to the fever in the Island of 
Boa Vista, and by others, what, it may be asked, was the object of their 
seclusion, and how is the reckless conduct of their visitors to be reconciled 
with that dread of the fever which, it is said, pervaded all classes? To 
wash and cook for these men is mentioned as the object of the visits of 
the woman; but, Dr. K. fears and believes, there was little, if any, occa- 
sion for such services. The woman sickened on the 12th, and died on the 
16th of October. 



1849.] 



King on Bod Vista Fever. 



131 



"The perplexing question then again occurs," continues Dr. K., " how did it hap- 
pen that the disease, if contagious, was not introduced into the town at an earlier 
period by the labourers, who were quite as much exposed as the soldiers to its 
presumed fatal influence, and were daily employed, from the 1st to the 13th of 
September, associating freely with their acquaintances, and sleeping every night 
in their own houses in the town ? 

" As misht be expected, there are a great many poor and miserable hovels in 
Porio Sal Rey, and there are dirt and filthiness everywhere; but in that part of the 
town called Biera, or Pao de Varella, where the woman who died on the 16th Oc- 
tober, and the soldiers, resided, the houses are of the lowest description, and the 
people who occupy them are generally very poor and destitute. But, independent 
of these remote causes of disease, which operate injuriously in every climate, 
there were others which claimed the pre-eminence. Swamps are numerous in 
the vicinity of Porto Sal Rey. But there is one large pool of stagnant salt and 
fresh water, immediately behind, but to windward of this part of the town: and 
still nearer to the houses, there is a locality which is resorted to by many of the 
people when obeying the calls of nature ; and the exhalations from the one, and 
the effluvia from the other, are blown by the usual winds in the direction of Biera. 
Should it be objected, that the operation of the same causes in former years did 
not produce the same deplorable results, I need only reply, that the season of 
1845 at Boa Vista was most unusual, and in many respects very remarkable. 
The late lamented Mr. M'Cauly, in his letter to the "Earl of Aberdeen, dated 24th 
September, 1845, writes as follows: 'But so long an interval had elapsed between 
the departure of the Eclair, and the appearance of this case of fever in the town 
(that of the woman who died on the 1 6th October), that we were all disposed, in 
the first instance, to attribute it, as well as the general sickness of the place, rather 
to stagnant water, which had settled in great quantity at the back of the town, 
joined with the great heat of the weather, and the dirty state of the streets.' And, 
Mr. Consul Kendall, in his official letter to the same nobleman, dated 22d Decem- 
ber, 1845, says: 'Up to the 9th of October, extraordinary heat, and the fall of a 
large quantity of rain had been experienced: events which were surprising to the 
oldest inhabitants.' The information I received in the island in 1846, fully corro- 
borated what is stated in the above extracts; which, with other concurrent circum- 
stances, led me to the conclusion, that at the end of September or beginning of 
October, the atmosphere had become vitiated and malarious." 

Fever, Dr. K. remarks, was not communicated to any individual in the 
house where the sick officers and their servants resided, or to any person 
in their immediate vicinity. The owner of the premises, the judge, and 
his two servants (Europeans), re-occupied the same house soon after the 
ship left. One of the servants, however, was attacked with fever, and 
died at the end of December, being an interval of three months after the 
ship's departure. 

The soiled clothes which had accumulated in the officers' cabins, from 
the time of their departure from Sierra Leone, were taken on shore at Porto 
Sal Rey the same evening the ship arrived, and distributed, next morning 
(22d August), to the washerwomen of the town. " Now," observes Dr. K., 
"if the disease possesses the power of reproduction, its poison must have 
been as certainly communicated through the medium of fomites as by 
direct contact with the sick on board or at the fort; yet none of the washer- 
women nor any in their families were attacked with fever until November; 
showing an interval of seventy days after exposure to the infection. Four 
of the washerwomen died from fever; the three first in December, and 
the last in January, 1846 ; but all the other members of their family re- 
covered." 

The same fever broke out at the end of October, in Joao Gallego, Fun- 
das Figuieras, and Cabeca Taraffe, on the eastern side of the island, and 
distant at least sixteen miles from Porto Sal Rey. They are separated 



132 



Beviews. 



[Jan. 



about one and a half miles from each other, but the common road to Ca- 
beca passes through the two former. 

"The first case of fever appeared in Cabeca Taraffe on the 27th October; the 
next, in the intermediate village of Fundas Figuieras, on the 31st of October; and 
the disease commenced in Joao Gallego, which isnearestto Porto Sal Rey, on the 
1st of November. Dr. K. received the above information from the Judge at Fun- 
das Figuieras. John Jamieson, the consul's store-keeper, who had the manage- 
ment and superintendence of all the labourers, stated to Dr. K., repeatedly, that 
none of the people belonging to the eastern villages were employed in any man- 
ner about the Eclair; and as it is well known they entertained the greatest dread 
of the fever, it is not reasonable to suppose that they had any communication 
with that vessel, either direct or indirect/"' 

At Estacio, or Old Town, situated about ten miles to the southward of 
Porto Sal Rey, where there must have been communication with the ship, as 
some of the labourers who had been employed on board, and at the fort, 
resided there, the fever did not appear until after the middle of November, 
two months, at least, after the Eclair's departure. The first death occurred 
on the 24th of November; four persons died in December, and in the rest 
of the twenty-two cases which terminated fatally, death occurred in Janu- 
ary and February, 1846. The above facts were communicated to Dr. K. 
by the Judge at Old Town. 

According to Dr. K., there are no grounds for believing that the disease 
was carried to any of the neighbouring islands by those who departed 
after the fever broke out in 1845. 

"The situation," remarks Dr. K., "of Porto Sal Rey, and the whole district of 
Rabil, in the immediate vicinity of -swamps and pools of stagnant water, and the 
patches of rich alluvial soil near the other villages, expose the inhabitants to those 
noxious exhalations, during the autumnal months, which are generally admitted 
to be the common remote causes of fever. The lower classes are extremely 
poor, and often badly fed; they breathe a polluted atmosphere in their crowded 
and ill-ventilated abodes; and there is a general disregard of cleanliness in the 
streets and about their houses. Now, such a combination of morbid causes would 
produce malignant fever in any part of the w#rld ; but in -Boa. Vista, in the year 
1845 and 1846, there was this addition or aggravation, — the common atmosphere 
was unusual and epidemical. 

"The testimony of the most intelligent men of the island, including Dr. Al- 
meida, Senor Baptista, (the consul's agent,) the mayor of Rabil, the Judge of 
Fundas Figuieras, the Judge at Old Town, removes every doubt as to the fact that 
fever prevails to a certain extent, and carries off several of the inhabitants in the 
months of November and December every year; and this endemic fever, which 
recurs annually, and which Dr. Almeida calls the bilious remittent, does not al- 
ways present the same mild aspect and character; on the contrary, it is well 
known that, in certain years, the disease was epidemical, and in comparison with 
other seasons, very fatal. 

11 It has been generally observed that the prevalence of malignant fevers, not 
only in Boa. Vista but elsewhere in tropical regions, is preceded and accompanied 
by an unusual and peculiar state of the atmosphere. Such was undoubtedly the 
case at Boa. Vista. Whether this peculiar constitution of the air depended on the 
causes just mentioned, or on some deleterious emanations from the earth or its 
surface, its general operation was evidently inimical to animal life in all its grada- 
tions. That the common air which was inhaled by every living thing on the island, 
was in an epidemic condition in the months of October, November and Decem- 
ber, in both years, is sufficiently demonstrated by the simultaneous occurrence of 
universal sickness and great mortality among the cattle (including cows, horses, 
mules, donkeys, and goats,) at the very same time that fever was raging among 
the inhabitants. And further, there was this remarkable coincidence, that after an 
interval of some months, and the disappearance of disease both in man and beast 



1849.] 



King on Boa Vista Fever. 



133 



the same fever broke out again in the towns and villages about the rainy season 
in the following year, and was again accompanied by the same murrain among 
the cattle, which in the two seasons proved fatal to two-thirds of the whole stock 
of the island." 

In regard to the fever which occurred on board the Eclair, Dr. K. thinks 
there can be no doubt that in some of the crew the disease was produced by 
malaria, to'which they were exposed upon the shores of the Sherbro river; 
it is improbable, however, he admits, that two of the men attached could 
have thus contracted the fever, and that it is doubtful, and indeed highly im- 
probable, that the remainder of the sick were in this manner infected. He is 
inclined to believe that a morbific cause, of a miasmatic nature, was generated 
in the foul holds of the ship, and which first manifested itself in the month 
of April, 1845. 

The malignancy of the fever, even at this time, maybe inferred from the 
great mortality, and the unavailing efforts of the surgeon in most of the 
cases to avert a fatal termination; one man died after an illness of three 
days ; two of five days ; two of six days ; two of seven days ; and one 
died on the 9th, one on the 11th, and one on the 13th day after they were 
attacked with the disease. 

It is admitted that the fever contracted by the crew of the frigate at the 
Sherbro river was the bilious remittent, a non-contagious disease, and the 
same term is applied to the disease by all the medical officers who had an 
opportunity of judging from personal observation. Dr. K. believes that 
the fever was essentially the same from the first to the last, and in all re- 
spects similar in its nature and character with the worst cases of that which 
occurred in the fort or on the island of Boa Vista. 

The fact of the arrival of the Eclair in a healthy state at Sierra Leone, 
on the 5th of July, is, Dr. K. remarks, quite incompatible with the idea 
that the previous fever was contagious. After leaving Sierra Leone, how- 
ever, the fever again broke out, and in a more aggravated form. The ques- 
tion, therefore, presents itself; was a new and specific disease communi- 
cated to the ship's company at this place 1 

The Eclair arrived at Sierra Leone on the 5th of July, and anchored close 
to the shore, where she remained until the 23d. Two days after their arrival 
the crew commenced cleaning and whitewashing the holds and store-rooms ; 
and they were again employed in the same duty at the end of July and 
beginning of August ; a part of the ship's company was also employed, at 
the same time, in cleaning the holds of the Albert, a vessel which had been 
engaged in the Niger expedition, and presented a strange accumulation of 
filth. The men were allowed to go on shore in small numbers at a time, 
in the midst of the rainy season. Some of those who came off at the 
expiration of their leave were allowed to go on shore a second time. 
Three men, although not sleeping on shore, remained until late ; and eleven 
men are said to have slept on shore, some of them for several nights. The 
men had been exposed, consequently, under the most unfavourable circum- 
stances, to the influence of morbific causes peculiar to the country, and at 
a season when few Europeans, lately arrived, escape an attack of the en- 
demic fever, and where, from local aggravations, fever of a malignant type 
might be expected. There was, however, no epidemic condition of the 
atmosphere, although it was the rainy season, nor anything unusual at 
that time, either in the nature or amount of disease in the settlement. 

" It is not hinted that the sailors were exposed to infection from persons actually 
labouring under the disease ; indeed; it is not certain there was a single case of 



134 



Reviews. 



[Jan. 



sporadic yellow fever in the town previous to their arrival; Dr. K. is hence at a 
loss to understand how its origin can be explained on the principles of contagion. 
The Eclair left Sierra Leone on the 23d of July, anchored some little time off the 
coast, and arrived at the Gambia on the 10th of August. In that short time, however, 
several men, chiefly those who remained on shore at Sierra Leone, were carried 
off by fever, some of them with black, vomit. After calling at Goree, the ship 
proceeded to Boa-Vista, where she arrived on the 2 1st of August. It appears by the 
surgeon's report, that from the 19lh of July, when the first case of fever was entered 
on the sick list, until the 3 1st of August, when the ship's company was disembarked 
at Boa Vista, 44 cases of fever occurred, and 16 of them terminated fatally. With- 
out assuming at present that there were any just grounds for believing that the 
cause or causes of the fever had a local origin in the ship, it may be inferred that 
this idea was entertained by the superior officers, or they would never have at- 
tempted to clear the holds at Sierra Leone in the rainy season, and within one 
month have commenced again the same laborious work at Boa Vista, and that it 
is equally improbable, but from some apprehension of the kind, that they would 
have removed the men from the ship, and lodged them, at that hot season, in such 
a miserable place as the fort at Boa Vista." 

Dr. K. describes this fort as a dilapidated, neglected building, incapable of 
affording proper accommodation for even 50 men, although 100 men from 
the Eclair were there huddled together, several of them labouring under a 
malignant fever. Immediately within the door was a receptacle two-thirds 
filled with rubbish, the accumulation probably of years, while in the opposite 
corner of the court were two common close privies. Independent of these 
sources of contamination, the plan of the building precluded a free circulation 
of air ; hence, when the place was overcrowded, and the clothes and bed- 
ding of the crew and convalescents were daily exposed for the purpose of 
airing, the atmosphere which the men breathed must, Dr. K. remarks, have 
been polluted and deleterious in the extreme. And with the thermometer at 
86° during the day, and probably heavy dews at night, the fever instead of 
subsiding, as was anticipated, raged with increased virulence. 

" But," inquired Dr. K. " does it necessarily follow from the aggravated cha- 
racter of the fever, and the great mortality at this place, that the disease was, or 
had then become contagious? I believe not. It is true, a greater number were 
attacked in a given time, but, after all, the ratio of mortality barely exceeded that 
in the fever off Sherbro. Whether the common atmosphere possessed any latent 
epidemic property at this time, I know not; but from the brief description I have 
given of the fort, I imagine few will deny that there must have been a concurrence 
of causes and circumstances, not only injurious to those who were ill, but likely to 
produce a malignant disease in others who were in perfect health, and as 1 am fully 
persuaded that the crew of the Eclair had been exposed for a length of time to 
the influence of some deleterious miasma generated in the ship, and which, by a 
combination of causes, had become highly concentrated, the melancholy occur- 
rences at the fort may, I think, be rationally explained without referring to the 
agency of contagion. The holds of the ship appeared to be clean at Boa-Vista, 
such also has been the case in other sickly ships, and yet, on examining minutely 
into hidden parts, it has seldom happened but accumulations of filth of some kind 
or other have been discovered, and justly referred to as the source of the disease. 
And such was actually the case in the Eclair, for long after the people left the 
ship in England, and when the engines were removed, mud some inches deep, 
was found under the flooring." 

We have thus presented a condensed view of the statements and views 
of Dr. K. in reference to the occurrence of fever in the island of Boa. Vista 
during the summer and autumn of 1845. By the facts adduced the reporter 
believes that he has shown, 1st. That the fever which occurred on board 
the Eclair, betweeen the 1st of April and her arrival at Boa Vista, was of 
malarious origin and not contagious. 



1849.] 



King on Bod Vista Fever. 



135 



2. That, although the latter island was healthy at the period of the 
arrival of the frigate and the landing of her crew, and the disease which 
subsequently prevailed there was identical with that which prevailed 
among the ship's crew, still that it was not introduced into the island by 
the sick from on board the frigate. 

3. That there is no evidence that the person, in whom the first case 
occurred at Boa Vista, had had any intercourse with the sick crew or with 
the ship, while the subsequent cases occurred at a period after the 
departure of the ship and the surviving portion of her crew, too remote 
to admit of the supposition that they were the result of a contagion 
communicated by the sick from on board the Eclair. 

4. That the increase of the fever, among the crew of the frigate after 
they were landed, is readily accounted for from the morbific influences to 
which they were exposed, without the necessity of supposing its propa- 
gation by contagion. 

5. That there were morbific causes existing upon the island capable of 
producing the fever, which is an endemic of the place, and to which those 
attacked were peculiarly exposed, and — 

6. Soon after the departure of the Eclair, the atmosphere of the island 
had become vitiated and malarious, and hence, that the occurrence and 
spread of the disease among the inhabitants were attributable to a genuine 
epidemic cause. 

The main points on which Dr. King and Dr. McWilliam are at issue, 
regarding the Boa Vista fever, rest, not so much upon any difference of 
opinion as to a certain series of events having occurred at that island, at a 
given time, and in a definite order, but, chiefly upon their respective views 
relative to the causes in which those events originated. They are both 
agreed, that the island was in a condition of the most perfect health, when 
the steamship Eclair arrived there, on the 21st of August, 1845, with a 
fever-stricken crew ; that, upon the sick being landed and lodged in a fort, 
on a small island, about half a mile from Boa Vista, the fever increased 
instead of becoming diminished in intensity; that the sick were re-embarked 
in the Eclair, on the 13th of September. That, during the occupancy of 
the fort by the sick of the Eclair, there was a small Portuguese guard 
stationed there, which was several times relieved ; that the guard, at the 
time the ship left, consisted of one negro and two European soldiers ; that 
within three days after the departure of the Eclair, both Europeans were 
attacked with fever, similar to that from which her crew had suffered, of 
which they both died, in the course of a few days. That the negro was 
also afterwards affected with fever, and on that account, he and another 
negro soldier, who had been sent from Boa Vista to nurse the sick Euro- 
peans, were removed from the small island to Boa. Vista, where, from 
fear of infecting their comrades, they were not received into the barracks, 
but lodged for some time in a house situated at one end of Porto Sal Rey ; 
and further, that a convict woman, who lived next door to that very house, 
was the first person who was attacked with, and died from fever in the 
town. 

Drs. King and McWilliam both state, that a person who had been a 
labourer on board the Eclair was the first individual, on the island of Boa 
Vista, attacked with fever, at least so as to attract attention. Dr. King 
says, this man was taken ill on the day after the Eclair sailed, September 
14th, but, Dr. McWilliam thinks there is more reason to believe that he 
was attacked on the 17th of that month. He was attacked at a village 
called Moradinha, situate in the Ravine of Rabil. 



136 



Reviews. 



[Jan. 



In regard to the two Portuguese soldiers, constituting the guard at the 
fort, who were first seized with the fever, Dr. King considers that they 
were both pre-eminently exposed to the attack of endemic fever, as they 
were both Europeans, but lately arrived in the colony. But where, Dr. 
McWilliam inquires, was this endemic cause ? 

" It is," he remarks, u I believe, generally, if not universally admitted, that the 
endemial source of fever in warm climates is the entity called 1 malaria,' for the 
developement of which, certain conditions of soil and of atmosphere, which [ 
need not here recapitulate, are essential. By the concurrent testimony of the late 
Mr. Macaulay, the Hon. Mrs. Macaulay, Mrs. Pettingall, and every one else with 
whom I spoke on the subject, the weather was never more beautiful than at the 
period in question. An extract from Consul Rendall's diary, which that gentleman 
sent me some time back, states: — 'September 13th, 1845. Growler and Eclair 
left for Teneriffe, or Madeira, en route for England; warm in the sun but with it 
cool breezes. The weather has been of this description from the arrival of the 
Eclair, and, to the date of her sailing, we had no rain. ; — So late in the month as 
from the 25th to the 30th of September, is reported ' as cool !' No mention is 
made of rain — and, it is not particularly noted — until the 5th of October. Captain 
Buckle's evidence as to the state of the weather during the week he was at Boa 
Vista, is to much the same effect. He says, ' the winds were N.E. to N. by E., sky 
always 6. c. A little rain fell once or twice during the night while we were there.' 
Dr. King, indeed, nowhere, in his Report, ventures to invoke the aid of malaria 
earlier than the end of September or beginning of October, P 

At this period, Dr. K. evidently sees no chance of establishing the 
existence of anything like a general endemial cause ; but, before abandon- 
ing it altogether, he offers a conjecture which Dr. McW. imagines to be 
too vague to have much weight in a philosophical inquiry. He says, 
" whether the common atmosphere possessed any latent epidemic property 
at this time, I know not." 

Dr. McW. admits the description, given by Dr. K., of the fort upon the 
small island, occupied by the Eclair's crew, to be correct, and also, that these 
men had been exposed on board of ship to a deleterious miasm, and even 
admits it as possible that the extension of the disease among them after their 
landing, may be explained without referring to the agency of contagion ; but 
insists, that the death of the two soldiers, whom all admit had never been on 
board the Eclair, cannot be thus accounted for. Dr. McW. does not believe 
that the condition of the fort, though doubtless favourable to ihe propaga- 
tion, if not to the exaltation in character, of yellow fever, was of itself 
capable of originating the disease. The polluted and deleterious state of 
the atmosphere, caused by the overcrowding of the place with the sick and 
well, and the daily exposure, for the purpose of ventilation, of the clothes 
and bedding of the crew, was, in his opinion, more likely to produce the 
fever. 

Dr. McW. and Dr. K. do not differ, very widely, in estimating the 
temperature of the atmosphere while the Eclair remained at Boa Vista. 
Dr. K. states it to have been 86° during the day; Dr. McW. considers 
this as the maximum heat, and gives 81° 80' as the daily average, the 
maximum seldom reaching 84°. 

Dr. K. says he has no reason for believing that any of the soldiers of 
the fort were permitted to enter the sick apartments ; but Dr. McW. has 
shown, from the examination of the soldiers themselves, that there is not 
the slightest doubt but that most, if not all of them, were in the sick 
apartments. 

11 One glance," he adds, 11 at the dimensions of the rooms of the house, will con- 
vince any one, upon a moment's consideration, that to accommodate the whole 



1849.] 



King on Bod Vista Fever. 



137 



of the Eclair's sick in them, was a physical impossibility ; consequently, some 
lay under tents or sheds in the court yard. The guard occupied a wretched shed 
called a cook house, close to the lower door of the house where most of the sick 
lay; some of them slept under the piazza, where they must have been trodden 
on, bv the sick going to the water closet. Moreover, from the small size of the 
whole enclosure (93 by 50 feet) containing so great a number of men, it was next to 
impossible for the soldiers, if they had been ever so careful, to avoid contact with 
the sick." 

It is beyond any doubt, Dr. McW. remarks, that soon after the death 
of the two white soldiers at the fort, the black was taken ill, and was in 
consequence sent, with a companion, to a house in the Beira Row of 
Porto Sal Rey. Next to this house lived a female, who was the first 
person seized, so, at least, as to attract any attention, with fever, and the 
first who died (about October 16th), in the town. A man, living twenty 
yards from her house, was dead from fever, on the 18th of October, and, 
next day after, a female, who lived in the next house to him, was attacked, 
while a European writer, who lived in the same row, was also seized and 
died towards the end of the month. Dr. King says that he was informed, 
by the coloured soldier sent from the fort, that he and his companion held 
no communication with any one while there ; but Dr. McW. adduces 
the evidence of the same soldier, contained in his former report, to prove, 
that the very reverse was the fact. He also appeals to the evidence of 
several other persons, contained in that report, to show, beyond doubt, 
that the female who lived next door to them, and many other individuals, 
visited them while they remained at Beira. 

'''The invasion of Porto Sal Rey by fever, remarks Dr. McW., forms an 
epoch, so to speak, of the epidemy, differing in one important particular from the 
whole of its antecedent history. By the time the female, living next to the house 
occupied by the coloured soldier, was taken ill, much rain had fallen, the weather 
had become more hot, and, in short, there now — but not before this — existed the 
recognized elements for malarious evolution." 

Dr. McW. observes, that here an important question presents itself — 
was either the origin or progress of the fever in Porto Sal Rey in con- 
formity with the laws of diseases caused by endemical influences? To ac- 
count for its origin at this place, Dr. K. refers to a large pool of stagnant 
salt and fresh water immediately behind and to windward of Beira, and a 
locality still nearer to the houses, resorted to by many people when obey- 
ing the calls of nature. The lower part of the Beira Row abuts on the 
beach ; and a little way above its upper extremity, the trappean rock crops 
out, and forms a ridge between the houses of Beira and the salt plain to 
windward, where only there could have been a pool of fresh and salt 
water. But, according to Dr. McW., the chief depot of fresh and salt 
water, is on the flat site of the salt pan, immediately behind the main 
body of the town. The shallow troughs in which the salt is formed cover 
a superficies of between three and four thousand square yards. When the 
rainy season had some time set in, the greater part of the plain, as far 
back as the Reshee Hill, is in a state of inundation, and the broad side of 
the whole town is thus immediately to leeward of a sheet of water. With 
reference to the other source of atmospheric pollution, mentioned by Dr. 
K., Dr. McW. admits that there are, or were, receptacles of the same kind 
in various parts of the town. 

"Here, then," Dr. McW. continues, " as regards Porto Sal Rey, there was at this 
time a general prevalence of those theoretic physical conditions by which fever 
may be caused. But was the manifestation of the disease also general, or in 



138 



Reviews. 



[Jan. 



accordance with the endemial law ? Most assuredly not. It was the very reverse ; 
for it was, for a considerable time, strictly local, being confined to Beira and its 
immediate neighbourhood. It is, surely, attributing too much to mere chance to 
suppose that an endemial cause should spare the inhabitants of Porto Sal Rey 
only so long as the soldiers kept away from the town ; that it should select for its 
operations, in preference to all others, the very locality, nay, the very house, in 
which those soldiers were lodged ; and that it should, still further, maintain its 
extraordinary capricious character, as to mark out for its first victim, the very 
woman who cooked for them. The non-appearance of the disease in Porto Sal 
Rey for so long a time, is thus easily accounted, for, and argues incontestably for 
its introduction to the town by the sick soldiers from the fort. For it is quite cer- 
tain that the fever did not show itself until the soldiers came to Beira. It would 
indeed be tedious here to recapitulate the whole of the evidence in my report, 
proving, from high and low, that the fever, in Porto Sal Rey, broke out in the 
person of the female who cooked for the soldiers ; radiated from her house to those 
in the immediate neighbourhood, and ultimately extending over the whole town; 
or, in other words, that its rise and progress were in harmony with the laws which 
regulate contagious disorders." 

Dr. K. thinks it remarkable that the fever, if contagious, was not intro- 
duced into the town at an earlier date by the labourers, who were, he says, 
quite as much exposed as the soldiers to its presumed fatal influence. Dr. 
McW. replies, that it is hardly possible that two bodies of men could have 
held positions more diametrically opposite to each other than the soldiers 
and labourers, with reference to the sick crew at the fort and the frigate. 
No labourer, with the exception of the slave who died, ever was within 
the walls of the fort, although some were at the gate to get water, while 
the sick were there ; but most, if not all of them were, at one time or another, 
on board the Eclair. On the other hand, no soldier was, at any time, 
on board the vessel, but all those who composed the several guards were, 
of course, in the fort with the sick. It clearly follows then, that the 
labourers were exposed to whatever sources of disease there may have 
been on board the vessel, but not to those that existed at the fort, while 
the soldiers, on the contrary, were rendered liable to whatever morbific 
cause there may have been at the fort, but not to any that may have been 
on board the vessel. 

"It is quite certain," observes Dr. McW., "that it was one of the labourers 
who was the first person attacked with fever in Rabil, where he must have arrived 
about the 25th of September. In the beginning of October one of his daughters 
was taken ill, and died in three days. Four days after she died, another daughter 
was seized, and she also died. Eight days after the second girl died, his son was 
attacked, and lived only five days. Lastly his wife was struck down on the day, 
or the day after the boy died, but in her case the fatal termination was protracted 
■until the fifteenth day of her illness. So that her death did not take place until 
the beginning of November." Meanwhile, on the first, and about the end of Sep- 
tember, and the beginning of October, respectively, a man, his wife, and two 
children, near neighbours of the above labourer, were attacked early in October; 
another neighbour, and the members of his family, between the 10th and 12th 
of October, and about the same time, still another of the same vicinity. "It is 
unnecessary," Dr. McW. remarks, "to trace the radiation of the fever, from this 
to other quarters of Cabecada. But Dr. K. denies that there is any evidence that 
the labourer taken sick at Rabil was ever within the influence of a specific con- 
tagion ; according, however, to Dr. McW., the man was for a day on the Eclair's 
lower deck pumping water, and, there was a strong suspicion of his having taken 
a coverlet belonging to one of the officers of the ship, and he was on board the 
ship the day the sick were re-embarked from the fort, and assisted in hoisting 
them in. It is true there were others on board at this time who were not atacked. 
But, Dr. McW. replies, " the case of this labourer bears every evidence of being 



1849.] 



King on Boa Vista Fever, 



139 



a positive instance of infection which is not to be controverted by any number of 
mere negative results." 

Dr. K. considers that Moradinha and the villages in its vicinity were 
in locality peculiarly adapted to the origination of endemic fever. This 
Dr. McW. admits, but asks, how far is the theoretic view of the subject 
borne out by actual facts ? 

" Fever broke out at Moradinha at a season of the year when there was nothing 
like any appreciable local physical condition to produce it. When fever was 
raging at Rabil, high above the ravine, there were only two persons at all sick in 
Moradinha, which lies almost in its bed. Again, Estacia de Baixo, which all the 
year round overlooks, and is nearer to, the site of the swamps, in the lower end. 
of the ravine, than any other part of the island, suffered least of all from the fever ; 
for, in a population of 256 persons, only three deaths took place, while the average 
mortality throughout the island was 1 in 15-4. Again, when fever re-appeared at 
Moradinha, it was at that season when, theoretically, malaria ; ought to have been 
least rife." 

In Estacia Velha (old town), Dr. McW. traces the importation of the 
fever to two persons who arrived sick from Rabil. Cabeca dos Tharafes 
was infected by the arrival of a sick female. Joao Gal/ego was perfectly 
healthy until the arrival of two sick soldiers from the barracks in Porto 
Sal Rey. For the evidence in support of these positions, we are referred 
to the official report of Dr. McWilliam. 

Drs. King and McWilliam nowhere differ as to the periods at which 
the several districts in the island were invaded by fever, so as in the 
least to affect the question at issue. Both notice particularly the fact of 
Estacia Vella and the other distant villages continuing so long healthy, 
while fever was raging elsewhere on the island. But their respective 
conclusions from this fact are in direct opposition. Dr. King regarding it 
as a proof against contagious propagation, while the other gentleman con- 
siders it as highly favouring such a view. The common atmosphere, ac- 
cording to Dr. K., in October, November, and December, possessed an 
epidemic constitution. 

"Had the epidemy at Boa Vista originated," argues Dr. McW., "in a cause so 
generally diffused as the common atmosphere, it is, I imagine, but right to expect 
that its appearance in the various districts should have been somewhat general 
and simultaneous, instead of its being, as we both admit, confined for periods to 
certain localities. Again, the supposition of there having been any general £ latent' 
atmospheric vitiation cannot be reasonably entertained; seeing that all the other 
islands of the group, within sight of each other, remained in their usual health. 
In my opinion, all that can be granted is this: that at Boa Vista, a considerable 
time after fever broke out, there existed the theoretic physical conditions to generate 
malaria: therefore malaria may have been produced, — if so, it must be allowed that 
the atmosphere may have then become in a state favourable to the propagation of the 
disease. To this extent, then, the postulate is admitted, but its corollary is not, on 
that account, to be largely or hastily adopted : for it is by no means free from 
exception. It has been seen that the fever could not only arise, but that it could 
spread without the aid of malaria; where malaria ought to have been most rife, 
there was least fever, and in the town of Ribiera Brava, in the neighbouring island 
of Nicolao, I saw the elements for malaric production in as great perfection as 
anywhere at Boa- Vista, yet San Nicolao was healthy, while at the same time 
fever was raging at Boa Vista. If, in short, it has been satisfactorily demonstrated 
that the Boa Vista epidemy did not owe its origin to malaria, it follows that its 
diffusion over the whole island may also have been perfectly uncontrolled by it, 
or by any other supposed abnormal atmospheric condition. 

" There is another species of evidence generally recognized as of some value 
in an inquiry of this kind, which Dr. K. has not noticed. I mean the negative evi- 



140 



Reviews. 



[Jan. 



dence derived from the isolation or segregation of healthy individuals, from in- 
fected districts. At Espinguera near Mount Broyat ; at Cantor near Mount Ochello ; 
and at Agua dos Caballos, situated little more than a mile from Cabeca dos Tharafes, 
where, as the name implies, are the elements for a local febrific cause, I saw so 
late as in May 1846, little colonies amounting in all to fifty-one persons, who, in 
the early period of the epidemic, had fled from Joao Gallego and other villages, 
and cut off all communication with them. Not one that remained was attacked. 
No one, they said, had had fever. 

11 Dr. King seems doubtful as to the symptoms having been so violent as repre- 
sented. It is quite in accordance with all experience, that in yellow fever, as well 
as in other tropical diseases, the symptoms are less strongly marked among the 
negro and mixed races, than among the whites. However, judging from the 
mortality, they must have been violent enough to satisfy the most fastidious on 
this head. The average mortality among the whole native population, slaves and 
free men, was 1 in 15.4. Of 56 European Portuguese who remained on the island, 
25 died; out of 11 English and Americans 7 died. In the barracks the whole force 
consisted of 41 rank and file, of whom 9- were European Portuguese, the rest 
natives of the Cape de Verds, chiefly negroes. Of the 9 Europeans 8 died: the 
last 6 at the barracks, all within three weeks." 

Dr. King states in his report that Dr. Almeida considered the disease to 
have been an aggravated type of the bilious remittent. On this point Dr. 
McWilliam presents a passage from the testimony of Dr. A. contained 
in the former report, and a letter from that gentleman dated June 31st, 1847 ; 
the first to show his opinion as to the nature of the epidemy eight months 
previous to Dr. K.'s visit to Boa Vista, that namely, it was yellow fever, 
and the same disease as prevailed among the crew of the Eclair, and which 
he had never before witnessed at Boa. Vista ; and the second, to prove that 
he entertained the same opinion six months after Dr. K. left the island. 
" I have," Dr. Almeida writes, " resided in this island thirty-eight years, 
as the only medical man of the place. I have treated the inhabitants of 
this island, of all and whatever sicknesses with which they have been 
attacked, and it has never come to my knowledge that contagious fevers 
have been introduced into this island, nor have originated in it ; but only 
fevers ' miasmctticas,' exhibited with intermittent and remittent symptoms, 
which only took place some years in the rainy season, from the effects of 
stagnant water in the ravine of Rahil, and attacked the people living in the 
neighbourhood thereof, whilst those in the other villages were exempt. It 
was only in the year 1845 that I have known in the island the contagious 
or yellow fever, which, unhappily, was introduced by Her British Majesty's 
Steam Vessel ' Eclair,' and to such an extent devastated this unfortunate 
people." 

Dr. McWilliam concludes his remarks upon Dr. King's report as 
follows. 

" I think, then, 'that the whole tenor of the evidence furnished regarding the 
Boa, Vista epidemy fully bears out the following conclusions, viz: — 

11 1. That the epidemy did not arise from any endemial source. 

11 a. Because fever appeared before any of the commonly recognized conditions 
to produce endemial causes existed. 

11 b. Because, even after these supposed endemial conditions existed, where 
malaria ought theoretically to have been most rife, there was least fever. 

(l 2. That the epidemy did not depend upon any general atmospheric vitiation. 

11 a. Because the whole of the other islands, which are within sight of each other, 
and all within the trade-wind influence, were, when fever raged at Boa Vista, in 
their usual health. 

u b. Because the manifestation of the epidemy was in no degree general or 
simultaneous, as it ought to have been, if it had been owing to a cause so diffused 



1849.] 



King on Bod Vista Fever. 



141 



as the common atmosphere, but was confined for long periods to certain localities, 
while other districts were wholly exempt from the disease. 

"3. That the Bod Vista epidemy is an instance in the history of yellow fever, in 
which that disease is proved to have been imported into, and afterwards diffused over an 
island, by virtue of infectious properties. 

11 a. Because Bob Vista was perfectly healthy until the arrival of H. H. S. Eclair 
there, with a fever-stricken crew. 

" b. Because fever of the same nature as that which afflicted the Eclair appeared 
among the inhabitants of Boa Vista, within a reasonable time after her departure 
from the island, and first in the persons of those who had been in direct intercourse 
with the sick crew. 

" g. Because the progress of the disease from one district to another, and from 
person to person, was, in every case, clearly traced to communication with infected, 
individuals. 

" d. Because isolation of healthy persons, in places remote from, as well as in 
places near to, sick villages, bestowed perfect immunity upon those who were 
thus segregated." 

We have thus laid before our readers an analysis of the Report of Dr. 
King, and of the Remarks upon that report published by Dr. McWilliams. 
The subject discussed in these documents is a most interesting one. Of the 
exact character of the disease which occurred on board the Eclair, and that 
which subsequently prevailed upon the island of Boa Vista, we have no 
precise facts to form a correct opinion. That the two were identical ap- 
pears to be admitted by all who had an opportunity of forming any judg- 
ment in relation to this point from personal experience. But whether the 
disease was actually yellow fever, or a malignant form of bilious remittent 
fever, or that form of malignant fever which has been denominated the 
Bulam fever, the question as to its essentially contagious or non-contagious 
nature is an all-important one, in reference as well to pathology as to public 
hygiene. Convinced that the yellow fever of this country is not capable 
of being communicated by contagion, and that the same is true of the seve- 
ral forms of remittent fever which prevail in different sections of the Uni- 
ted States, we have been inclined to scrutinize very closely the facts and 
deductions presented in the two documents of Dr. McWilliams, in proof of 
the contagious character of the Boa Vista fever, and to give full weight to 
the statements and arguments adduced by Dr. King to prove its strictly 
endemic origin, altogether independent of any connection with the landing 
of the sick crew of the Eclair in the immediate vicinity of that island, and 
its subsequent spread, from the same local causes by which it was gene- 
rated in the first instance. After the most careful examination of the sub- 
ject as presented by these several documents, we are constrained to confess, 
very candidly, and we admit, somewhat reluctantly, that Dr. King has failed 
in his attempt to invalidate the conclusions of Dr. McWilliams, logically 
deduced from a connected series of well defined facts. If it be possible to 
prove the communication of a disease by contagion without the test of ac- 
tual inoculation, the facts presented by this gentleman and not disproved by 
Dr. K., prove, that the fever which occurred in Boa Vista was introduced 
by the sick from on board the Eclair, and communicated from individual to 
individual, until it finally extended to the mass of the population. 

We regret extremely that the true pathological character of the disease 
in question has not been more accurately made out. The mere statements 
of individuals, even though highly respectable in reference to their profes- 
sional standing, as to the nature of an epidemic fever, cannot be received 
as conclusive; the only positive and satisfactory evidence on this point is 
No. XXXIIL— Jan., 1849. 10 



142 



Reviews. 



[Jan. 



that derived from an accurate statement of the entire history of the disease, 
and of its pathological anatomy. In the absence of this evidence we have 
no right to conclude that the Boa Vista fever was the same disease as the 
yellow fever of the United States, or to infer that the latter is propagated 
by contagion, even occasionally or contingently, from the fact that the con- 
tagious character of the Boa, Vista fever may be admitted to have been in- 
controvertibly established. D. F. C. 



1849.] 



143 



BIBLIOGRAPHICAL NOTICES. 

Art. XX. — Essays on Infant Therapeutics : to which are added Observations on Ergot, 
and an account of the origin of the vse of Mercury in Inflammatory Complaints. 
By John B. Beck, M.D., Professor of Materia Medica and Medical Jurispru- 
dence in the College of Physicians and Surgeons of the University of the 
State of New York, &c. &c. New York, 1849: 12mo. pp. 117. W. E. Dean, 
Publisher. 

Dr. Beck has done well in collecting together, as he has done in the present 
work, the essays, published by him, at different periods, in the Medical Journals, 
on the effects of opium, emetics, mercury, blisters, and blood-letting on the 
young subject. These essays relate to very important points in the therapeutics of 
infancy, and embody, not only the experience of many of the most authoritative 
writers in reference to the questions discussed, but a series of practical observa- 
tions upon the employment of the therapeutic agents enumerated, in the several 
diseases of the infant to which they are adapted. 

While the remedies embraced in the essays of Dr. Beck are unquestionably 
all important in many of the affections incident to the early periods of life, still, 
as their effects are modified by the physiological condition, as well as by the.patho- 
logical tendencies of the infant organism, they demand in their exhibition, much 
judgment, with a constant attention to the injurious and even fatal results which are 
liable to result when they are improperly or incautiously administered. 

The remarks of Dr. Beck upon each of these remedies, the leading circum- 
stances under which its use may be beneficial or injurious, and the proper mode 
of its employment, are clear and judicious, and will be found of great value at the 
bed-side, by the younger members, especially, of the profession. 

The two essays which are appended, the one on the effects upon the uterus of 
the ergot, and the second, on the origin of the use of mercury in inflammatory 
complaints, are interesting. The first is marked by much good sense, and although 
we do not entirely concur with the author in all his conclusions, still they are so 
generally correct, that we feel no disposiiion to enter into a discussion ol the few 
points in regard to which we differ from him. D. ¥. C. 



Art. XXL — Die Krankheiten der MHz; Eine pnthologisch-therapevtische Abhamllung, 
von Carl Berthold Heinrich, A A. L L., Mag. Doct. d. Phil. Med. u. Chir. etc. 
etc. Leipzig, 1847: 8vo. pp. 452. 

The Diseases of the Spleen: A Pathologico-therapeutic Treatise. By Charles B. 
Heinrich, M. D., &c. &c 

There is scarcely an organ of the animal body of which we know so little as 
we do of the spleen. Its anatomical structure has, it is true, been minutely 
studied, but in regard to its functions there is scarcely a single point that has been 
fully established. From an early period, the uses of this organ have been the 
subject of much curious speculation ; and so discordant and ridiculous were the 
opinions upon this'subject of the older physicians, we can scarcely be surprised 
that some were inclined to the belief that the spleen serves no oiher pur- 
pose than to preserve the equilibrium of the body by counterbalancing the liver, 
or to fill what would otherwise have been a vacant space in the abdomen. 

As a necessary consequence of the obscurity involving its physiology, and the 
comparatively trifling amount of disturbance produced by the abnormal conditions 
of the spleen, its pathology has not attracted much attention. Its morbid anatomy 



144 



Bibliographical Notices. 



[Jan. 



is minutely described in connection with that of the several affections in which the 
organ is involved, bat beyond this the investigation of its pathology has made but 
trifling advances. 

To investigate the various diseased conditions of this curious organ — their 
etiology, symptomatology, diagnosis, and treatment, is the object of the work before 
us. The author has collected, with much industry, the observations in reference 
to the pathology and therapeutics of the several diseased conditions of the spleen, 
that are scattered through the writings of the leading medical authorities of the 
past and present centuries, and has added whatever facts his own experience has 
enabled him to verify. 

The treatise commences with an admirable and minute account of the deve- 
lopment and anatomical structure of the spleen, followed by an inquiry into its 
physiology. 

The author believes that, from the position of the spleen, its immediate connec- 
tion with the stomach and the several organs appertaining to the portal system, a 
connection shown, especially, by its sympathy with these organs in health and 
disease, its character as a chylopoietic agent may be reasonably inferred. He, 
therefore, includes it among the lymphatic glands — which, in its anatomical struc- 
ture, it closely resembles. He remarks, that a spleen is present only in those 
classes of animals in wmich a distinct lymphatic system has been detected, while 
its size is always in proportion to the development of that system. Inflammation 
of the lymphatic vessels not unfrequently accompanies hypertrophy of the spleen, 
as a sympathetic phenomenon; while hypertrophy of the spleen is often a con- 
sequence of disease of the lymphatic glands of the abdomen, or is observed as a 
symptom of general scrofula. Dr. Heinrich, in evidence of the spleen being a 
lymphatic gland, adduces, further, the observations of Mayer and Czermak, who 
observed the mesenteric glands to become enlarged after extirpation of the spleen, 
and that of Tiedemann, who, after the same experiment, observed an enlargement 
of the thyroid gland to take place; the latter being, according to our author, an 
organ nearly related to the spleen. These observations are adduced to prove 
identity of office, by showing that a vicarious activity takes place in other lym- 
phatic glands in order to supply the action of the removed spleen. According 
to our author, the special office of the spleen, an office which it possesses in com- 
mon with the mesenteric glands, is, as was supposed by Hewson, to separate from 
the materials furnished by the portal vessels the colouring matter of the blood, 
and at the same time to remove from the newly absorbed chyle any excess of 
watery fluid. Its peculiar cellular texture, interwoven with a network of blood- 
vessels and lymphatics, aptly fits it, he conceives, for this office, which, as is 
shown by experiments upon the lower animals, is most actively performed about 
four or five hours after a meal — that is, after full chymification. 

The influence of the spleen in the formation of the colouring matter of the 
blood, our author considers to be evinced by the fact, that it is only in red-blooded 
animals a spleen is met with. It is further shown by the circumstance, that in 
animals from whom the spleen has been extirpated, the gall-bladder contains but 
a small quantity of colourless bile; as well as by the observation, that the diseases 
which are attended by a softened, hypertrophied or hardened condition of the 
spleen, are all characterized by an abnormal chemical condition of the blood, 
evinced in a defect of the quantity and quality of the hsematin; hence the earthy, 
pale, or even green hue of the skin of those patients who are affected with any 
of the splenic cachexia. This view of the functions of the spleen throws some 
light, Dr. H. conceives, upon the well-known specific influence which the pre- 
parations of iron exert over the greater portion of the splenic affections. 

When the function of the spleen is disturbed, Dr. H. believes, that a general 
dyscrasia ensues, which he denominates the melanotic ; and from which proceeds a 
number of secondary forms. The cruor of the blood being diminished, and the 
serous portion proportionately increased — there is produced, according to the dif- 
ferent grades and modifications of this change in the composition of the blood, 
the several forms of anasmia, dropsy, chlorosis, scurvy, purpura, and petechia; 
all of these affections being, according to Dr. H., more or less dependent upon 
a diseased condition — especially tumefaction and softening — of the spleen. 

Our author would appear to adopt, in part, the opinion of Oesterlen, by admit- 



1849.] 



Heinrich on the Diseases of the Spleen. 



145 



ting that the spleen co-operates with the liver in freeing the blood from any excess 
of fat. 

The spleen, therefore, he considers to be an organ which prepares the blood for 
the action of the liver, while the latter performs the same office for the lungs. 

Dr. Heinrich considers that, besides these active functions of the liver, it per- 
forms, also, a passive office by acting, as Rush taught, the part of a diverticulum, to 
protect the more important organs in its vicinity from an over-distension of their 
vessels with blood, to which they would otherwise have been liable under a 
variety of circumstances. 

A general idea of the author's views in relation to the pathology of the spleen, 
may be gathered from the following remarks, which constitute the substance of 
the chapter which treats on the tendency of the spleen to disease. 

He commences by referring to the generally received doctrine, that the predis- 
position of an organ to disease is always in direct proportion to its physiological 
importance. This observation, founded upon a too broad application of the phy- 
siological character of an organ to explain its pathological tendency, can, he is of 
opinion, be received only in a restricted sense, if it be not, in the greater number 
of cases, positively false. The spleen, he observes, I have shown, is believed 
to be one of those glandular bodies to which a by no means high physiological 
importance can be ascribed, inasmuch as its functions may be sufficiently supplied 
by the vicarious action of other organs. Nevertheless it belongs, confessedly, to 
that class of organs which are the most frequently found in a diseased condition ; 
and this often in cases, in which, during the lifetime of the patient, no trace of 
functional disturbance had been detected. 

While it is admitted that a part which is deficient in nerves is. in consequence, 
possessed of a less amount of vital activity, it does not follow, that a part so cir- 
cumstanced is less disposed to take on diseased action. This is proved by the 
fact, that the heart and many other organs which, in common with the spleen, 
possess but a proportionately small number of nerves, are particularly predisposed 
to disease. The conditions upon which the predisposition of a part to disease de- 
pends are rather, its greater or less exposure to morbid influences, the number and 
importance of its sympathetic connections with other organs, and its consequent 
susceptibility to partake of the diseased. conditions of the latter. 

The spleen, by its deep, concealed position in the abdomen, beneath the short- 
Tibs, is. to a very great extent, secured from mechanical injury. Its communication 
with external influences takes place, principally, through the stomach, lungs, and 
skin, by means of the absorbents and blood-vessels. When the lymph becomes 
impregnated with any foreign noxious matter, the spleen is bv this readily excited 
to morbid action. This is evidenced by the almost constant affection of the spleen, 
which is observed, as a secondary symptom, in the different morbid conditions of 
the blood. And. inasmuch as the morbid condition of this organ, in the several 
crasis. is distinguished by characteristic phenomena, the spleen becomes in a cer- 
tain sense an indicator of the different dyscrasia. 

The sympathies by which the spleen is connected with neighbouring and remote 
parts of the organism, are extremely important and numerous. In his glance at 
the physiology of the organ, Dr. H. presents a general sketch of these sympathies. 
He attempts to show that the functions of the spleen have an intimate relation to 
those of the liver and lungs; holding thus, as it were, the medium between the 
two latter organs, in carrying on the process of haematosis. 

The spleen is, also, more or less connected with the whole of the lymphatic 
system, and to the entire circuit of the organs appertaining to the portal circulation, 
as is proved by the reciprocal assistance they yield to each other when any ab- 
normal change occurs in the activity of one or other of them. 

As the spleen forms, also, a natural reservoir which, under certain circumstances, 
receives any excess occurring in the mass of the blood, and in this manner shields 
the vessels of even remote parts from sudden and excessive distension and con- 
sequent rupture: it is, therefore, liable to morbid turgescence upon any sudden 
disturbance of the circulation in other parts of the body, as, for example, after am- 
putation of the leg or arm, and in various ways, when in this condition, to be made 
the centre of morbid action. This the more readily takes place if the spleen be 



146 



Bibliographical Notices. 



[Jan. 



already in a diseased state — either inclined to atrophy or hardening, or in a state 

of commencing suppuration. 

Finally, observation proves that the spleen, from its position behind the stomach 
and in the immediate vicinity of the solar plexus, partly by pressure made by it 
upon this important nervous network, and partly by inducing a secondary affection 
of the nervous system, especially in cases of dyscrasia resulting from disease of 
the organ, becomes the cause of certain anomalous reflex symptoms ; mostly pro- 
duced b}' abnormal action of the sympathetic nerve. 

From what has been said, it must be evident how difficult it is to delineate a 
case of splenic disease, in which various consensual phenomena, resulting from 
the disturbance of other organs, will not be present. So prominent, in fact, are 
the latter, in many instances, that they appear earlier and are more decidedly 
marked than those immediately dependent upon the organ primarily affected. On 
the other hand, we are authorized to conclude, from the active consent which exists 
between the spleen and other organs, that the irritation, occurring primarily in one 
of the latter, particularly in one of those which are more immediately connected 
together by the portal circulation, may be readily reflected upon the spleen, and 
there excite a morbid action by which disease shall, be again extended throughout 
the body. In this category are included all those diseases which result from a 
contagious poison, and are attended by splenic tumefaction. 

In regard to the portion of the spleen most prone to disease, our author remarks 
that his observations lead him to conclude the portion nearest to the hilus or portee 
is that in which morbid action is the most readily and frequently excited. This 
accords with the law laid down by Classen, that in membranous and glandular 
organs, there is invariably a greater inclination to disease at their orifices than at 
other portions of them. Next to the hilus, the part most frequently and readily 
diseased is the enveloping membrane, which is often found softened or thickened, 
or the seat of cartilaginous or bony degeneration, the former being most commonly 
the result of preceding inflammation, either confined to the portion of peritoneum 
covering the spleen or extending to it from another portion of the peritoneal mem- 
brane. 

An irritation of the spleen, even of a normal character, sustained by the move- 
ments of the diaphragm, may, by various circumstances, be considerably increased, 
and at length become the cause of morbid changes. This explains the greater pre- 
disposition to disease of the upper over the lower portion of the spleen, especially 
the more frequent occurrence in this part of tubercles, abscesses, and the indica- 
tions of various forms of inflammation. 

Of the other points connected with the etiology of the splenic diseases, as pre- 
sented by our author, we can only present a very brief sketch. 

In certain families he believes there is more than in others a pronenessto affec- 
tions of the spleen. 

Females he believes to be in general more liable to disease of the spleen than 
males, if we except wounds and external injuries. Splenic tumefaction he sets 
down as a common result of derangements of the menstrual function. 

Diseases of the spleen in general, he describes as of most common occurrence 
during the middle period of life. But when we refer to the individual forms of 
splenic disease we find tuberculation to be most common in childhood; certain 
forms of enlargement of the organ and their consequences, like the intermittent fever 
with which they are connected, are almost invariably confined to the adult age; 
the morbus maculosus Werlhofii, chlorosis, and other general diseased conditions 
more or less dependent upon splenic disease, are confined to the period of develop- 
ment, while true scurvy, which is also often dependent upon tumefaction of that 
organ, is observed at a later period. Very great softening, amounting to diffluerice 
of the texture of the spleen, is very seldom met with in young persons, but is very 
common during middle and more advanced age. Atrophy, hardening and car- 
tilaginous degeneration belong to the period of old age. 

According to our author, there can be no doubt that certain constitutions and 
temperaments are more predisposed than others to splenic disease. Marcus de- 
scribes this constitution and temperament as being indicated by a dark complexion, 
proneness to sadness and melancholy; timidity, meditation, an easy excitation to 
tears; sourness of stomach, and heartburn. The greater number of suicidal 



1849.] 



Heinrich on the Diseases of the Spleen. 



147 



monomaniacs, Marcus adds, are affected with a morbid condition of the spleen. 
While our author admits the general correctness of this description, he considers 
the remark in relation to the majority of suicidal monomaniacs being those af- 
fected with splenic disease, as an exaggeration. 

As a general rule, it may be stated, that the temperament usually described as 
the lymphatico-venous, is the one in which disease of the spleen is of most fre- 
quent occurrence. In persons of this temperament the spleen is perhaps already 
to a certain degree diseased. 

Our author enumerates scurvy as one of the most prominent of the causes of 
splenic disease. Softening of the spleen he describes as a common consequence of 
intemperance, of the mercurial cachexy, and of intermittent, typhus and exanthe- 
matic fevers, and pyamia. He refers to the case described by Heusinger in 
which a metastasis of inflammation took place from the parotid to the spleen ; 
to the two observations of Scudamore in which splenitis followed an attack of 
gout, and to the remark of Heusinger that he has known the occurrence of inflam- 
mation of the spleen during gout to cause a temporary abatement of the local 
phenomena of the latter. 

Among the physical causes of splenic disease Dr. H. enumerates severe 
blows or falls upon the left hypochondrium. In cases in which tumefaction and 
softening of the liver are already present, blows or falls may produce a rupture of 
its enveloping membrane, and give rise to a fatal hemorrhage into the abdominal 
cavity. The spleen is liable to be wounded when morbidly enlarged, or when, 
during digestion, it is distended with blood. The author refers to a curious case 
described by Mayer, in which a lumbricoid worm, after having penetrated through 
the coats of the colon, had entered deeply into the substance of the spleen, caus- 
ing inflammation of the latter. He sets down as a cause of acute splenitis the 
drinking of cold water when the body is overheated, or the sudden chilling of 
the body after exposure to the heat of the sun, which latter, Heusinger had already 
described as one of the most active causes of splenic inflammation. Other causes 
of tumefaction and even inflammation of the spleen, are, he remarks, the sudden 
arrest of the menses or of the hemorrhoidal flux ; over-distension of the organ with 
blood, after the amputation of a limb, long-continued running, or swimming, or 
excessive dancing. The tumefaction and inflammation of the spleen occurrring 
in drunkards, gluttons, &c, and in persons exposed to malaria, he believes to be 
caused as much by an excessive distension and irritation of the texture of the organ, 
as by the morbid change produced in the composition of the blood. Splenic dis- 
ease is also, we are told, liable to result from terror, fear, grief, despondency, and 
other depressing affections of the mind. 

Our author refers to a case of tumefaction of the spleen, described by JBree, oc- 
curring in a female after being, in a frolic, six times successively immersed in the 
sea. The neglect of periodical blood-letting Dr. H. describes as a cause of melan- 
choly with disease of the spleen. The immoderate use of alcoholic drinks, by 
overloading the blood with carbon, produces a dyscrasia which is connected either 
with simple tumefaction of the spleen, with tumefaction and softening, or with 
atrophy or scirrhous hardening. Disease of the spleen is produced, also, by drink- 
ing the water of swampy grounds. 

The articles of food which predispose to disease of the spleen are described 
as, the grains rich in amylaceous matter, the legumina, potatoes, the fat vegeta- 
ble oils, saccharine substances ; and in short all those nutritive substances which 
introduce into the circulation a large amount of carbon and hydrogen. 

The narcotics, especially the hydrocyanic acid, which, when taken into the sys- 
tem in a certain amount, produce a decomposition of the entire mass of the cir- 
culating fluid, reducing the blood to a black, thin fluid, are enumerated as among 
the causes which produce a distension and softening of the spleen. H. Meyer, 
however, in his experiments with hydrocyanic acid upon different classes of ani- 
mals, positively asserts, that while in no case did the blood after death fail to co- 
agulate, he never found the blood-cells altered, and he makes no mention of any 
morbid appearance in the spleen. Very similar, we are told, to the effects of the 
hydrocyanic acid upon the blood and spleen, are those of the sulphuret of am- 
monia and sulphuretted hydrogen. Similar effects are produced by the poison of 
certain forms of typhus, and by different kinds of miasmata. 



148 



Bibliographical Notices. 



[Jan. 



All those habits and occupations which predispose to abdominal plethora or 
cause repeated pressure or bruising of the abdomen, are liable, according to Dr. 
H., to give rise to splenic disease, as for instance a sedentary position of the body, 
shoemaking, weaving, &c. 

Meteorological causes, according to our author, promote the occurrence of 
splenic disease, in so far as atmospherical heat predisposes to disease of all the 
gastric organs, attended with disturbance of the functions of the liver. The spleen 
especially suffers in wet, swampy regions, when the atmosphere is hot and loaded 
with moisture. 

In regard to the localities in which disease of the spleen is of most frequent 
occurrence, Dr. H. remarks, that it is in low, frequently overflowed, swampy re- 
gions, lying at the mouth of large rivers, or at the base of mountains, and in damp 
valleys, with a hot, sultry atmosphere, that the chronic affections of the spleen 
atul other glands prevail. Hence the frequency of these in both the Indies, in 
many parts of Africa, and in different portions of North America. In Brazil, dis- 
eases of the spleen, we are told, are less general than in other tropical climates. In 
the south of Europe, particularly in Italy. Sicily, and Spain, splenic disease is of 
frequent occurrence; the same is true of Holland, and of the Rheingau. 

The symptomatology and general diagnosis of the diseases of the spleen are 
considered at great length by Dr. Heinrich : these questions, with the nearly allied 
ones of the complications and differential diagnoses, occupy no less than one 
hundred and sixty pages. The author commences by noticing the frequent absence 
of characteristic symptoms, and then describes, in detail, the local and consensual 
painful sensations in the neighbourhood of the left hypochondrium ; pointing out, 
however, the mistake that would occur, were, from these symptoms alone, the pre- 
sence of splenic disease inferred, as the pains may result from disease of the left 
lung, the heart, the diaphragm, the peritoneum, the stomach, the left lobe of the 
liver, the cauda of the pancreas, the omentum, the transverse and descending 
portions of the colon, or the left kidney. The character and circumstances of the 
pain in the different forms of splenic disease are next minutely described. The 
diagnoses of the several forms of splenic disease by the sight and touch, are the 
subject of the ensuing section. The predominance of the symptoms in the left 
hypochondrium is referred to as a diagnostic symptom. Functional disturbance 
of the gastric organs is noticed — thirst — increase or diminution of appetite — a 
desire for particular articles of food — sour or bitter taste in the mouth — acid eruc- 
tations — whitish or yellow coating of the tongue, or redness and dryness of this 
organ, or finally a bluish colour of the tongue, with indentations of its edges — 
sponginess of the gums, with offensive breath — ptyalism — nausea and vomiting. 
DiarrhoBa is noticed as occasionally but not invariably present, excepting in chronic 
cases accompanied with intumescence and hardening of the spleen; most com- 
monly there is obstinate costiveness with colicky pains. A consideration of the 
functional disturbance of the respiratory organs follows. These our author considers 
as chiefly secondary. A minute inquiry is entered into, in regard to the reaction of 
the circulatory system, and some cases are next detailed in which a close connection 
between disease of the spleen and of the sexual organs is inferred. Then follows 
an account of the abnormal state of the blood in splenic diseases, which does not 
admit of an analysis that would be satisfactory to our readers. The colour of the 
skin and habitus of the patient are the subjects next considered. The author no- 
tices ecchymosis, pemphigus, and pompholyx, as common accompaniments of 
splenic disease, as also erysipelas, erythema, herpes, and other forms of eruptions. 
Hemorrhoids, hemorrhages from the stomach and bowels, and mela3na, are also 
frequent in diseases of this organ. The conditions of the urinary secretion claim 
next attention: then follow the nervous symptoms. 

The author enters very fully into a consideration of the complications of the 
affections of the spleen with the diseases of other organs, and the several forms 
of fever. 

He denies that a morbid condition of the spleen has any specific etiological rela- 
tion to intermittent fever, as some have supposed, but is invariably a consequence 
of the latter. In typhus and typhoid fever Dr. H. describes the enlargement and 
softening of the spleen, as one of the most important symptoms. In yellow fever 



1849.] 



Heinrich on the Diseases of the Spleen. 



149 



the same morbid condition of the organ is occasionally met with, but only as a 
secondary affection. 

Our author describes a form of epilepsy which he denominates epilepsia splenica. 

Morbid alterations of the spleen, he remarks, are very commonly met with in 
those who have died from epilepsy, but it would be erroneous from this to conclude 
that the disease of the spleen had been the cause of the epilepsy. It is, never- 
theless, very evident, that congestion and consequent enlargement and hardening 
of that organ are frequently a consequence of epilepsy; but those cases only are 
to be considered as those of genuine splenic epilepsy, in which the indications of an 
idiopathic affection of the spleen precedes the epileptic seizure, and the cure of 
which is to be effected by a treatment calculated to restore the normal condition 
of the spleen as well as to remove the disturbance of the nervous system. 

The author's consideration of the general treatment of the diseases of the spleen 
occupies forty-four pages. His remedies are, general and local blood-letting in cases 
of acute splenitis; rubefacients after depletion and in chronic cases; in these latter, 
also, caustic applications to produce suppuration ; setons, moxa, and the actual 
cautery; purgatives; in acute cases, the saline articles, laxatives, and enemata; 
in chronic cases the more active purgatives; in these latter, calomel, iodine, the 
preparations of iron, the mineral acids, both internally and externally, especially 
the nitric acid ; the aqua chlorica, the hydrochlorate of ammonia; the seeds of the 
St. Mary's thistle, the geum urbanum, the squill; in the atonic condition of the 
spleen, and the consequent dropsical effusion, gum ammoniac with aloes. The 
radix belladonna in small doses is, according to Dr. H., useful in cases of chronic 
obstruction of the circulation and the consequent intumescence of the spleen ; the 
conium in combination with calomel is also recommended by many writers. The 
sulphate of quinia is considered by some as an effective remedy in nearly all the 
chronic forms of splenic disease. 

Our author devotes a section to the consideration of extirpation of the spleen as 
a remedy for certain of its diseased conditions; without, however, recommending 
or condemning it. 

Having finished the general consideration of the pathology and therapeutics of 
the diseases of the spleen, Dr. H. describes next each form of these diseases 
specially. 

The first of these is a morbid increase of the vital activity of the spleen. Hy- 
peremia with consequent hypertrophia and neuralgia ; the 2d. Morbid diminution of 
the vital activity of the spleen, 1, Hyperemia and intumescence with alteration of struc- 
ture, and its connection with the production of the fibrinous, fatty, albuminous, and 
serous crasis, and the peterochymeusis of Simon, splenitic tumour with morbid 
changes in the lymphatic apparatus. 2. Atrophy of the spleen, phlebolitia ; 3. Sehnen 
fleche, or the exudation of firm, white, tendon-like, inseparable exudations, which 
occasionally occur upon the upper surface of the spleen, as well as upon the sur- 
face of other organs; 4. Cartilaginous, bony, and earthy degeneration of the spleen. 
Next follow, Inflammation — 1. Episplenilis ; inflammation of the capsule; 2. Sple- 
nitis; inflammation of the substance of the organ, acute and chronic, with its ter- 
minations in hepatization, suppuration, softening, and gangrene; 3. Inflammation 
of the splenic veins. After these, emphysema of the spleen, pseudo-morphosis, 
viz., melanosis, lipoma and steatoma, hydatids and acephalocysts, scirrhus, and 
tubercles, are considered, and finally, rupture of the spleen, rupture of the splenic 
artery, with or without the formation of aneurism, rupture of the splenic vein, 
wounds of the spleen, with some remarks on congenital abnormalities of the organ. 

The work of Dr. Heinrich is, to say the least of it, a highly interesting one. It 
comprises a careful analysis and arrangement of the observations bearing upon 
the subject of which it treats, furnished from different sources: with an attempt to 
base upon these a correct pathology of the spleen. We have presented a suf- 
ficiently full outline of the author's views on this subject, to enable our readers 
to judge of their general character; we should have extended our notice, so 
as to include a fuller exposition, especially, of his account of the particular dis- 
eases of the spleen — their history, anatomical phenomena, symptoms, course, 
effects, and treatment, had it been possible to do so without occupying a space 
beyond what the importance of the subject merits. After a careful perusal of 
all the facts adduced by Dr. H. ? we cannot concede to the pathological condi- 



150 



Bibliographical Notices. 



[Jan. 



tions of the spleen so powerful an influence in the production and modification 
of disease as he claims for them. We very much doubt whether it can be shown, 
that the several morbid states of the organ are other than the effects — often, in- 
deed, very remote ones — of morbid action in other organs, and we must confess 
that w T e are without any evidence that the splenic diseases cause any important 
change in the phenomena thence resulting, or are the means of the still further 
extension of preceding or concomitant disease. Our author himself confesses, 
that important changes in the spleen are frequently detected after death, in cases 
in which not the slightest suspicion of a morbid state of the organ existed during 
the lifetime of the patient. Again, that it is scarcely possible to meet with a 
case of splenic disease unattended by some prominent disease of other organs; 
and, finally, that it is always extremely difficult. — excepting in cases of extensive 
tumefaction of the organ. — to make out the existence of. or accurately to deter- 
mine the character and extent of. the several diseased states of the spleen. 

D. F. C. 



Art. XXIT. — Researches on the 31otion of the Juices in the Animal Body. By Justus Lie- 
big, M. D., Professor of Chemistry in the University of Giessen. Edited from the 
manuscript of the author. By William Gregort,M. D., Professor of Chemistry 
in the University of Edinburgh. Edited from the English edition. By Eben N. 
Horsford, A. M., Romford Professor in the University at Cambridge. 12mo. 
pp. 99. Lowell, 1848. Daniel Bixby & Company. 

This is an interesting little work, in which the Giessen Professor, whose name 
is already familiar to our readers, presents a series of experiments, the object of 
which is to ascertain the law according to which the mixture of two liquids sepa- 
rated by a membrane, takes place. 

In the course of this investigation, the author informs us, that the more intimate 
study of the phenomena of Endosmosis impressed on him the conviction, that, in 
the organism of many classes of animals, causes of the motion of the juices were 
in operation far more powerful than that to which the name of Endosmosis has 
been given. 

The causes here alluded to, are the pressure of the atmosphere, as well as its 
hygrometric state. These, by influencing the transpiration from the skin and 
lungs, are essentially concerned in producing the motions of the animal juices— 
the passage of the digested food through the membranes of the intestinal canal, 
and its entrance into the blood ; the passage of the nutrient fluid outwards from 
the blood-vessels, and its motion towards the parts where its constituents acquire 
vital properties. 

The general positions assumed by Dr. Liebig are. that the constituents of the 
food, which have assumed a soluble form in the alimentary canal, mix with the 
fluids of the body, and in connection with these, are distributed, by the blood- 
vessels, to all parts of the organism. That the movement and distribution of these 
fluids, and of all the substances dissolved in them, exclusive of the mechanical 
cause of the contraction of the heart, by which the circulation of the blood is 
effected, depend, 1. on the permeability of the walls of all vessels to these fluids; 
2, on the pressure of the atmosphere ; and 3. on the chemical attraction which the 
various fluids of the body exert on each other. That the motion of all fluids in 
the body is effected by means of water, a certain amount of which, in the normal 
state, all parts of the animal organism contain, and upon the presence of which 
depend several of their physical properties. That the power which the solids of 
the animal body possess of taking up water into their substance, and of being 
penetrable to water, extends to all fluids allied to water, that is, mixible with it. 
That this permeability to fluids the animal tissues possess in common with all 
porous bodies, and is determined by the same cause which produces the ascent 
of fluids in narrow tubes, or in the pores of a sponge — phenomena which we are 
accustomed to include under the name of capillary action. That the fluid which 
thus penetrates into the pores of a porous body can be effected by a mechanical 
pressure, and may be accelerated by increasing this pressure, and by all such 



1849.] Liebig on the Motion of the Juices in the Animal Body. 151 



causes as diminish the mutual attraction of the fluid molecules or the attraction 
of the walls of the pores lor these molecules. 

All the animal tissues, Dr. L. remarks, have, evidently, pores in certain direc- 
tions, although these pores are so minute that they are not, in the case of most 
tissues, perceptible even with the aid of the best microscopes. 

According to our author, it is the water which is not chemically combined with 
the tissues which has the greatest share in the production of the properties which 
these possess in the fresh state. 

The amount of pressure required to cause liquids to flow through the pores of 
animal textures, Dr. L. has shown to depend on the thickness of the membrane, 
as well as on the chemical nature of the different liquids. The power of a liquid 
to filter through an animal membrane bears no relation to the mobility of its par- 
ticles, for. it is shown by Dr. L., that under a pressure which causes water, brine, or oil 
to pass through, the far more mobile alcohol does not pass. The capacity of the 
animal membrane for being moistened by, and its power of absorbing the liquid, 
have a certain share in producing the result of its filtration through the membrane. 

From the experiments detailed by our author, it is shown, that the absorptive 
power of animal membranes for different liquids is very different: of all liquids, 
pure water is taken up in the largest quantity; and the absorptive power for solu- 
tion of salt diminishes in a certain ratio as the proportion of salt increases. A 
similar relation holds between the membranes and alcohol; for a mixture of alco- 
hol and water is taken up more abundantly the less alcohol it contains. 

After showing the phenomena produced when animal membranes saturated 
with water are placed in contact with alcohol or common salt, the author re- 
marks: — 

11 The relation of bladder, fibrine, and other animal substances when saturated 
with water, to alcohol and brine, proves that the shrinking — diminution of volume 
— of these tissues does not depend on a simple abstraction of water, in virtue of 
the affinity of alcohol and of salt for that liquid; for it is quite certain that the 
attraction of alcohol to water, and that of water to alcohol, are respectively equal. 
The attraction of the water within the tissue for the alcohol without, is just as strong 
as the power of the alcohol without to combine with the water within. Less alco- 
hol is taken up, and more water given out, because the animal tissue has less 
attraction for the mixture of alcohol and water than for pure water alone. The 
alcohol without becomes diluted, the water within becomes mixed with a certain 
proportion of alcohol, and this exchange is only arrested when the attraction of 
the w^ater for the animal tissue, and its attraction for alcohol, come to counterpoise 
each other." 

All fluids which, when brought together, suffer a change in their nature and 
properties, when only separated by animal membrane, mix together in the pores 
of the membrane, and a decomposition takes place in its substance. 

After considering the phenomena of mixture through a membrane, with change 
of volume, Dr. L. remarks, that the change of volume does not depend alone upon 
the different densities of the liquids; the membrane, in consequence of its porous 
structure, takes a distinct share in the process. The admixture of two liquids of 
dissimilar nature and characters always, according to our author, depends on a 
chemical attraction. But while the manifestation of chemical affinity is invariable 
whenever two dissimilar bodies come in contact, yet chemical combination is 
not. in all cases, the result of contact. Combination is only one of the effects of 
affinity, and occurs when the attraction is stronger than all the obstacles which 
are opposed to its manifestation. 

With respect to the change of volume in the two liquids which become mixed 
through animal membranes, we must consider, Dr. L. remarks, that the moisten- 
ing or the absorbent power of a solid body, as well as the power of a liquid to 
moisten other bodies, is modified by the different properties or chemical charac- 
ters of the liquid. The water absorbed by an animal tissue, when it enters the 
capillary tubes, exerts, also, by virtue of its attraction for the tubes, a certain pres- 
sure, by which the vessels are swollen and enlarged. The particles of liquid in 
these tubes undergo a counter pressure from the elastic parietes; by which pres- 
sure, when the attraction of the liquid particles for the solids is diminished by any- 
new cause, the amount of expelled fluid is increased. 



152 



Bibliographical Notices. 



[Jan. 



'■In all cases, we are told, where a permanent change in the volume of two 
liquids, separated by a membrane, is observed during their mixture, it is always 
accompanied by a permanent difference in the nature or properties of the two 
liquids; and from this it follows, that the molecules of the animal membrane must 
be, during the mixture, in an alternate state of contraction and swelling, or dilata- 
tion ; that is, in a continual motion. 73 

From the experiments of Dr. L. it would appear, that animal membranes have 
less power of absorbing a solution of albumen than all other substances; and that 
a small amount of mineral or organic acids increases the power of transudation of 
water, as well as of solutions of many organic substances. 

The causes which influence rapidity of mixture of two liquids, separated by a 
membrane, are, according to our author, the thickness of the membrane influencing 
the velocity with which the mixture formed in the pores and on both surfaces of 
the membrane changes its place, and the original difference in the quality of the 
two liquids is renewed. The velocity of transference diminishes with the amount 
of difference in properties between the two liquids. 

" If/'' Dr. L. remarks, " we suppose the membrane to be difficultly permeable 
for one liquid, while the other is easily taken up into its pores, and if we reflect, 
that this second liquid, on entering into the pores of the membrane, in virtue of 
the attraction of their walls for it, acquires a certain velocity, which permits it to 
pa-s beyond the extremities of the canal or of the pores, so as entirely to fill the 
pores, and to come in direct contact with the liquid on the outside of the pores, it 
follows, that, when this second liquid moves past the pores with a certain velocity, 
the absorbed liquid must follow it during the mixture, and there must take place 
a rapid transference of the second liquid to the first, — a true suction, as if by a 
pump. 

" The animal body is an example of an apparatus of this kind in the most per- 
fect form. The blood-vessels contain a liquid for which their walls are, in the 
normal state, far less permeable than for all the other fluids of the body. The 
blood moves in them with a certain velocity, and is kept at all times in a nearly 
uniform state of concentration by a special apparatus, namely, the urinary organs. 

" The whole intestinal canal is surrounded with this system of blood-vessels, 
and all the animal fluids, in so far as they are capable of being taken up by the 
parietes of the intestinal canal, and of the blood-vessels situated around it, are 
rapidly mixed with the blood. The volume of the blood increases, if no compen- 
sation is effected by means of the kidneys, and the intestine is emptied of the 
liquids contained iti it. The intestinal glands, through which this transference is 
effected, and each of which represents a similar apparatus of suction, contain 
within them two systems of canals. — blood-vessels and lacteals: the blood-vessels 
are placed next to the external absorbent surface; the lacteals chiefly occupy the 
central part of the gland. The liquids circulating in these two systems have very 
unequal velocities, and as the blood moves much faster in the blood-vessels, we 
perceive how it happens that the fluids of the intestine are chiefly (in quantity 
and velocity), taken up into the circulation. 

" The difference in the absorbent power of the parietes of the intestinal canal 
for liquids which contain different amounts of dissolved matters is easily observed 
in the effects produced on the organism by water and saline solutions. If we 
take, while fasting, every ten minutes, a glass of ordinary spring water, the saline 
contents of which are much less than those of the blood, there occurs, after the 
second glass (each glass containing 4 ounces), an evacuation of coloured urine, 
the weight of which is very nearly equal to that of the first glass; and after taking 
in this way 20 such glasses of water, we have had 19 evacuations of urine, the 
last of which is colourless, and contains hardly more saline matter than the spring 
water. If we make the same experiment with water containing as much saline 
matter as the blood (£ to 1 per cent, of sea salt), there is no unusual discharge of 
urine, and it is difficult to drink more than three glasses of such water. A sense 
of repletion, pressure, and weight of the stomach point out, that water as strongly 
charged with saline matter as the blood requires a longer time for its absorption 
into the blood-vessels. Finally, if we drink a solution containing rather more salt 
than the blood, a more or less decided catharsis ensues. 

u The action of solution of salt is of three kinds, according to the proportion of 



1849.] Liebig on the Motion of the Juices in the Animal Body. 153 



salt. Spring water is taken up into the blood-vessels with great rapidity : while 
these vessels exhibit a very small power of absorption for water containing the 
same proportion of salt as the blood does: and a still more strong saline solution 
passes oat of the body, — not through the kidneys, but through the intestinal canal. 

" Saline solutions and water, given in the form of enemaia, exhibit similar phe- 
nomena in the rectum. ;; 

"Since." remarks Dr. L., "the chemical nature and the mechanical character 
of membrane's and skins exert the greatest influence on the distribution of the 
fluids of the animal body, the relations of each membrane presenting any pecu- 
liarity of structure, or of the different glands and systems of vessels, deserve to be 
investigated by careful experiment ; and it might very likely be found that, in the 
secretion of the milk, the bile, the urine, the sweat, &c, the membranes and cell- 
walls play a far more important part than we are inclined to ascribe to them : that, 
besides their physical properties, they possess certain chemical properties, by 
which they are enabled to produce decompositions and combinations, true ana- 
lyses : and if this were ascertained, the influence of chemical agents, of remedies, 
and of poisons on those properties would be at once explained. ;; 

A series of experiments are next presented, to determine the influence of the 
cutaneous evaporation on the motion of the fluids of the animal body. 

" The most general expression, it is remarked, for these experiments and results 
is this, — that all liquids, which are in connection with a membrane from the sur- 
face of which evaporation can lake place, must acquire motion towards that 
membrane. The amount of this motion is directly proportional to the rapidity of 
evaporation, and consequently to the temperature and hygrometric state of the 
atmosphere. 

" That the skin of animals, and the cutaneous transpiration, as well as the evapo- 
ration from the internal surface of the lungs, exert an important influence on the 
vital processes, and thereby on the state of health, has been admitted by physicians 
ever since medicine has existed; but no one has hitherto ascertained precisely in 
what way this happens. From what has gone before, it can hardly be doubted, 
that one of the most important functions of the skin consists in the share which it 
takes in the motion and distribution of the fluids of the body. 

" The surface of the body of a number of animals consists of a covering or skin 
permeable for liquids, from which when, as in the case of the lung, it is in contact 
with the atmosphere, an evaporation of water, according to the hygrometric state 
and temperature of the air, constantly goes on. If we now keep in mind, that 
every part of the body has to sustain the pressure of the atmosphere, and that the 
gaseous fluids and liquids contained in the body oppose to this pressure a perfect! v 
equal resistance, it is clear that, by the evaporation of the skin and lungs, and in 
consequence of the absorbent power of the skin for the liquid in contact with it. a 
difference in the pressure below the surface of the evaporating skin occurs. The 
external pressure increases, and in an equal degree the pressure from within 
towards the skin. If now the structure of the cutaneous surface does not permit 
a diminution of its volume, a compression (in consequence of the loss of liquid 
by evaporation), it is obvious that an equalization of this difference in pressure can 
only take place from within outwards: first from within, and especially from those 
parts which are in closest contact with the atmosphere, and which offer the least 
resistance to the action of the external pressure. Hence it follows, that the fluids 
of the body, in consequence of the cutaneous and pulmonary transpiration, acquire 
a motion towards the skin and lungs, which must be accelerated by the circulation 
of the blood. By this evaporation, the laws of the mixture of dissimilar liquids, 
separated by a membrane, must be essentially modified. 

"The passage of the food dissolved in the alimentary canal, and of the lymph 
into the blood-vessels, the expulsion of the nutritive fluid out of the minuter blood- 
vessels, the uniform distribution of these fluids in the body, the absorbent power 
of the membranes and skins, which, under the actual pressure, are permeable for 
the liquids in contact with them, are under the influence of the difference in the 
atmospheric pressure, which is caused by the evaporation of the fluids of the skin 
and lungs. 

" The juices and fluids of the body distribute themselves, according to the thick- 
ness of the walls of the vessels, and" their permeability for these fluids, uniformly 



154 



Bibliographical Notices. 



[Jan. 



through the whole body; and the influence which a residence in dry or in moist 
air, at great elevations, or at the level of the sea, may exert on the health, in so 
far as the evaporation may be thus accelerated or retarded, requires no special 
explanation; while, on the other hand, the suppression of the cutaneous transpira- 
tion must be followed by a disturbance of this motion, in consequence of which 
the normal process is changed where this occurs. The pressure which, in conse- 
quence of the evaporation, urges the fluids within the body to move towards the 
skin, is, as may be readily understood, equal to the difference of pressure acting 
on the surface of the skin." 

The author points to the fact that the experiments described in the work before 
us, in so far as they permit us to draw conclusions as to the cause of the motion 
of the juices of the animal body, agree in all respects with the observations made 
on plants by Stephen Hales, more than 120 years since. 

The experiments and deductions of Hales are next examined. In the course of 
these Dr. L. refers to the potato rot, which he refers to the same cause as the blight 
in hops — a stagnation of the juices of the plant in consequence of suppressed 
transpiration; this latter being the result of a combination of certain conditions 
accidentally coincident. The cause being the same that in spring and autumn 
excites influenza, that is, the disease is the effect of the temperature and hygro- 
metric state of the atmosphere, by which, in consequence of the disturbance of 
the normal transpiration, a check is suddenly, or for a considerable time, given to 
the motion of the fluids, which is one chief condition of life, and which thus be- 
comes insufficient for the purposes of health, or even hurtful to the individual. 

In our notice of the work of Dr. Liebig we have attempted nothing further than 
a mere outline of the general conclusions deduced by the author from the expe- 
riments detailed. To understand fully these views the experiments must be 
carefully examined and compared with the comments by which they are accom- 
panied. Upon the accuracy of the views of Dr. L., as to the causes of the motion 
and due distribution of the juices of the animal body, we offer no opinion. To a 
certain extent they have, no doubt, some foundation in truth. We fear, however, 
that the zeal of a certain class of modern physiologists to explain the functions of 
the different parts of the animal organism by the physical and chemical properties 
of the tissues and fluids which enter into their composition, has led them to forget, 
that the property of vitality is a very important element in carrying on or con- 
trolling most of the organic actions of the living body. 

We append the remarks of Dr. Gregory, contained in the preface to the English 
edition ; which it is important to keep constantly in memory, in our investigation 
of the important subjects embraced in the investigation of Dr. Liebig. 

" While it is proved, that the mechanical causes of pressure and evaporation, 
and the chemical composition of its fluids and membranes, have a more direct, 
constant, and essential influence on the motion of the animal fluids, and conse- 
quently on the state of the health, than has been usually supposed, it is evident 
that very much remains to be done in tracing that influence under the ever-vary- 
ing circumstances of the animal body, and in applying the knowledge thus acquired 
to the purposes of hygiene and therapeutics. But it is equally obvious, that the 
above-mentioned mechanical and chemical causes are not alone sufficient to ex- 
plain the phenomena of animal life, since they are present equally in a dead and 
in a living body, so that, while every advance in physiology enables us to explain 
more facts on chemical and mechanical principles, something always remains, 
which, for the present, is beyond our reach, and which may forever remain so." 

D. F. C. 



Art. XXIII. — The Nature and Treatment of Deafness and Diseases of the Ear : and the 
Treatment of the Deaf and Dumb. By William Dufton, M. R. C. S. Philade- 
phia: Lea & Blanchard, 1848 : 12mo. pp. 120. With a Plate. 

This little volume commends itself to the profession by the modesty and good 
sense which characterize it. _The author does not profess to have made any bril- 
liant discoveries in the treatment of aural diseases, nor has he endeavoured to 



1849.] 



Clinical Midwifery. 



155 



make a huge volume by minutely detailing the structure of all the parts which 
compose the ear, with a description of their functions; but leaving these to be 
learned from the various works on anatomy and physiology, and contenting him- 
self with the more practical part of the subject, he has given a short account of 
the pathology and treatment of the principal diseases of the organ. 

The work is divided into three chapters. In the first the author treats of in- 
flammation of the ear generally, both chronic and acute and its consequences. 
In the second' of inflammation, chronic and acute, of particular parts, as well as 
of the growth of tumours, and the introduction of foreign bodies into the ear. 
The third chapter is devoted to the consideration of those diseases of the ear 
which, not being inflammatory, are referred to a particular state of the nerves of 
the part. 

If the knowledge of the nature and treatment of diseases of the ear has not 
kept pace with the progress of other departments of our science, the fault is to 
be ascribed as much to the neglect of medical men to devote themselves to the 
investigation of these affections, as to the inherent difficulties of the subject. The 
student and country practitioner, who has not the time or opportunity to study the 
more elaborate works on the subject, will find, in this unpretending volume, much 
useful information respecting the character and treatment of the principal diseases 
of the ear. 



Art. XXIV. — Clinical Midwifery ; comprising the Histories of five hundred and forty- 
five cases of difficult, 'preternatural and complicated Labour. With Com mentaries. By 
Robert Lee, M. D., F. R. S., Physician to the British Lying-in Hospital and St. 
Marylebone Infirmary, Lecturer on Midwifery at St. George's Hospital. First 
American from the second London Edition. Philadelphia, Lea & Blanchard, 
1849: pp. 235, 12mo. 

This volume consists of a series of eight Reports, comprising, as the author 
states, the most important practical details of all the cases of difficult parturition 
which have come under his observation during the last fifteen years, and of which 
he has preserved histories. They have been collected and arranged for publica- 
tion, in the hope that they may be found to illustrate, confirm, or correct the rules 
laid down by systematic operators for the treatment of difficult labours, and supply 
that course of clinical instruction in midwifery, the want of which has been so 
often experienced by practitioners at the commencement of their career. 

A volume containing the practical experience of so competent an observer as 
Dr. Lee could not be otherwise than valuable, and we commend this one to the 
profession as being a storehouse of valuable facts and precedents, to which they 
may refer to with confidence in cases of difficulty. 

The first Report contains observations on the present state of operative mid- 
wifery; and a succinct account of all the cases (eighty) of difficult parturition, 
which have fallen under the author's observation, in which the midwifery forceps 
was employed, or it had been proposed to have recourse to it, with a view of 
illustrating the various circumstances which render it necessary to employ this 
instrument, of determining the positive good we derive from it, and the injurious 
consequences which result when it is rashly and injudiciously applied. 

The second Report is devoted to an account of difficult labours from distortion of 
the pelvis, swelling of the soft parts, convulsions, hydrocephalus in the foetus, and 
other causes, in which delivery was effected by the operation of craniotomy. 

The third Report treats of the induction of premature labour in cases of dis- 
tortion of the pelvis; cancer of the gravid uterus; uterine and ovarian cysts and 
tumours; organic and nervous diseases of the heart; dropsy of the amnion ; ob- 
stinate vomiting; hemorrhage from the bowels; chorea and insanity during preg- 
nancy. 

The fourth report contains the histories of one hundred and one cases of pre- 
ternatural labour. 

The fifth report comprises the histories of sixty two cases of placental presenta- 
tion. 



156 



Bibliographical Notices. 



[Jan. 



The sixth Report embraces the histories of forty-four cases of uterine hemor- 
rhage in the latter months of pregnancy, during labour and after parturition. 

In the seventh Report are given the histories of thirty-five cases of retention of 
the placenta. 

The eighth and last Report comprises the histories of forty-eight cases of puer- 
peral convulsions. 

From the above catalogue raisonnee of the contents of this volume it will be per- 
ceived that it embraces most of the cases of difficulty which present themselves 
to the obstetrical practitioner; and coming as it does with the high authority of 
Dr. Lee's name, it is unnecessary for us to say anything further in its commendation. 



Art. XXV. — The Principles and Practice of Medicine, in a Series of Essays. By John 
VV. Hood, M. D. " By the union of study and practice, we attain a knowledge 
of the profession.' 7 8vo. pp. 263: Philadelphia, Thomas, Cowperthwait & Co.. 
1848. 

One original medical work, remarks a late writer, even though replete with 
faults, is of more value than all the well executed compilations which the press 
pours forth annually. Admitting the truth of this dictum, there will be little diffi- 
culty in arriving at a correct appreciation of the value of the Principles and Prac- 
tice of Medicine of Dr. Hood. The author is no " retailer of other men's opinions ;" 
finding no light from books to direct him in his investigation into the causes, 
nature, and treatment of diseases, he discarded them at once, making nature alone 
his study. And "from the teachings of the animal economy in post-mortem ex- 
aminations, and the effect of morbific and remedial agents in clinical observa- 
tions," he has derived principles that give to the work before us, in which they 
are embodied, a greater amount of originality than any other that has appeared 
for a long time can justly claim. 

In pathology, the leading position of Dr Hood is, that the source of a numerous 
class of diseases is an error loci of the abdominal viscera — their being forced, by 
various causes, from their natural positions. 

Upon this simple proposition he has founded an entire system of pathology, ex- 
planatory of the causation of nearly all the diseases to which the human organism 
is liable, " hidden for ages from the wise and skillful" of our profession, and now 
brought forward in a form designed to enlighten " the obscurity of our science," 
and take the place of the "fine spun theories" which have heretofore "misled 
the weak and obscured the pathway of the medical student." 

The manner in which Dr. Hood was led to a knowledge of the true pathology 
of a long list of the most frequent and, heretofore, least manageable diseases the 
physician is called upon to treat, is at once curious and instructive. We give it 
in his own words:— 

" In the second year of my professional career, I was called to attend a case of 
bilious colic, and, after exhausting the remedies that are usually applied, the pos- 
sibility of relief was suggested by reversing the erect position, or suspending, for 
a few minutes, the patient by the feet. A successful trial in a similar case had 
been witnessed, and, as the usual remedies in this had failed, I directed the ex- 
periment to be made. The patient at the time was covered with a cold clammy 
sweat, and on the change of position, and immediately after the concussion given 
by the operators, a quantity of gas escaped — a free alvine discharge was made 
from the bowels, and in twenty minutes the patient was entirely relieved from the 
symptoms of colic." 

In this naif statement of our author, we perceive the importance of an admoni- 
tion given, if we recollect right, by Dr. Rush, never to despise the prescription of 
even an ignorant nurse. It has perhaps been the fruit of much experience, and 
though often injudiciously administered by unprofessional hands, it may neverthe- 
less become, when carefully adapted to the proper cases and periods of disease, 
a valuable addition to our remedial agents. Not only has Dr. Hood found that to 
" invert the body or elevate the hips" is a useful remedy in ordinary constipation, 
but from the effects of this " heels over head" mode of curing bilious colic, his 



1849.] Druitt's Principles and Practice of Modern Surgery. 157 



mind was directed to a series of inquiries resulting in the pathological discoveries, 
a synopsis of which is siven above. Truly may it be said, in the language of our 
author. i: that if the profession could be made familiar with the natural laws of life, 
and wiih the organs, their position, and functions, it would lead to a better adapta- 
tion of our remedial agents, and a more certain relief to the afflicted." 

The causes of disease having been thus traced to displacement of the abdomi- 
nal organs, " the treatment is simple, as the indications are easily made out." 

;, 'Oiie of the most important is to remove the antecedent cause, and restore the 
displaced organs to their primitive position, and give support to the abdominal 
muscles, whose normal condition is requisite to maintain their restoration. Me- 
chanical agency, then, being the first indication, medicinal agents may be given 
in accordance, as the different stages of the disease may indicate." 

Dr. Hood has devised a variety of pads, and trusses, and supporters, which 
had before been never dreamed of, and has applied them to the treatment of a 
great variety of cases, in which it was never before supposed they could be of any 
use. 

We fear that after all the trouble Dr. Hood has undergone in the composition of 
these essays, and the pains we have taken to present a sketch of their teachings, 
to our professional brethren, they will be esteemed as of little value in their sight. 

There may be even some who will affect to believe that the essays of Dr. Hood 
have been written, and his theory of disease invented, solely for "the purpose of 
recommending certain mechanical instruments of support which he has invented, 
and of which he would fain dispose. D. F. C. 



Art. XXYT. — The Principles and Practice of Modern Surgery. By Robert Druttt, 
F. R. C. S. — A New American, from the Last and Improved London Edition. Edited 
by F. W. Sap.gent, M. D., Author of " Minor Surgery," &c. Illustrated with 193 
wood engravings. Philadelphia: Lea & Blanchard, 1848: pp. 576, 8vo. 

The fact that this work, in little more than six years, has gone through four edi- 
tions in England, and we believe a like number in this country, is sufficient 
evidence that it has met the wants of students and fulfilled the objects of its pub- 
lication. We must not, however, allow this opportunity to pass without noticing 
the great improvements introduced into the present edition. The extensive cir- 
culation which the work has had, has stimulated the author to renewed exertions 
to render it more worthy of the favour bestowed on it. -'The labour of such a 
revisal as was necessary to bring this edition up to the present level of surgical 
knowledge," the author states in his preface — ''short as has been the interval be- 
tween it and the preceding edition — has been very little less than that required 
for the original composition of the work. It is, as Dr. Johnson observed, very 
difficult to alter without leaving a blot; and therefore, wherever extensive altera- 
tions have been required, I have thought it best to write the whole passage afresh." 
We observe numerous additions to the practical parts of the work, and the intro- 
duction of many wood engravings. 

The editor has performed his part with judgment. His additions consist of 
notices of the results of the skill of American surgeons, and the introduction of a 
very large number of illustrations. 

We do not know any other treatise on surgery of the same size which is so 
copiously illustrated as this, or which contains an equal amount of sound surgical 
doctrine and practice; and we are sure it will continue to be a favourite text-book 
with students. 



No. XXXIII.— Jan., 1849. 11 



158 



Bibliographical No tices. 



[Jan. 



Art. XXVII. — A System of Human Anatomy. General and Special. By Erasmus 
Wilson, M. D., Lecturer on Anatomy, London. Fourth American from the last 
London edition. Edited by Paul B. Goddard, A. M., M. D., Prof. Anat. and 
Histology in Franklin Med. College: with two hundred and fifty-one illustrations 
by Gilbert. Philad.: Lea & Blanchard. 1848. 

The extraordinary favour which this work has received, notwithstanding the 
numerous others extant on the same subject, affords the strongest proof that it pos- 
sesses real merits. In less than eight years it has gone through four unusually large 
editions in England, arid an equal number in this country. That this success is 
deserved, no one, we believe, will question. Dr. Wilson's work possesses, indeed, 
all the qualities required tor a text book of anatomy. Its arrangement is good — 
the descriptions are remarkably lucid, perspicuous, and concise; and the illustra- 
tions numerous and distinct. These illustrations have, with very few exceptions, 
the merit also of being original, and are from dissections prepared expressly for 
this work. In each successive edition the author has availed himself of all the 
recent observations and discoveries in anatomy which have interest, and he has 
thus endeavoured to distinguish his volume as -the Record of the Profession at 
large, and not as the text-book merely of a particular school." 

The editor has written art introductory chapter on histology, and added a large 
number of new cuts — among others, an important series on the nerves. 

The publishers have also done their part well, and given to the work all the 
advantages of the best typographical execution; indeed, it has more the appear- 
ance of an edition de luxe prepared for the bibliopolists ; than a text-book for ana- 
tomical students. 



Art. XXVIII. — A complete practical work on the Nature and Treatment of Venereal Dis- 
eases and other affections of the Genito-Urinary organs of the male and female. Illus- 
trated by a great number of beautifully coloured plates: and many finely executed 
illustrations on wood. By Homer Bostwick, M. D., &c. New York: Published 
by Burgess, Stringer & Co., 1848 : pp. 348, 4to. 

A Treatise onthe Nature and Treatment of Seminal Diseases, Impotency, and other kindred 
affections: with practical directions fur the management and removal of the cause pro- 
ducing them : together with hints to young men. Illustrated by numerous engravings. 
Bv Homer Bostwick, Sunreon. Second edition. New York: Burgess, Stringer 
& Co., 1848: pp. 251, 12rno. 

The aim of the author of these works, we are led to suspect, is to obtain notoriety , 
not fame: the motive which prompted to their publication, the acquisition of 
pelf, not the communication to the profession of useful information of which it 
was previously not in possession. The author appears entirely to have mistaken 
the noble mission of the physician, which is to alleviate human sufferings and to 
cure disease, wholly irrespective of any sordid motives. Having said enough, we 
hope, to prevent our readers being imposed upon, we shall not notice these works 
further, as we believe we can better fill our pages than by occupying them with 
an exposition of plagiarisms and inaccuracies, which latter not being put forthwith 
the sanction of a name to give them any weight, are not likely to do mischief. 



1849.] 



159 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

TS THE 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. On the Spleen. By Drs. Verga and Tigrl— Dr. Yerga detailed to the Scienziati 
at Venice the results of his multiplied experiments upon the removal of the spleen 
of cats, dogs. &c. He arrived at the following conclusions: — 1. Nature does not 
constantly provide animals who have been deprived of their spleens with a new 
one, nor with a greater development of the liver, the thyroid body, the omentum, 
or the mesenteric glands. 2. Obesity, salacity, or sterility, are not constant or 
frequent effects of its removal. 3. Among the least unfrequent phenomena is 
to be noted during life, a greater vivacity, conjoined with a tendency to tabes, 
notwithstanding a keen appetite; and after death various alterations in the liver. 

Dr. Yerga was opposed to considering the spleen as performing a mere 
mechanical office, as a diverticulum of the blood in the case of impeded circula- 
tion; but still he was desirous of giving some account to the congress of Dr. 
Tigri's researches, who had discovered in a special condition of the vessels of the 
human spleen — a mechanism which he termed a li compensator for the circula- 
tion. ; ' He found, as far as the eye and the scalpel could pursue them, that the 
splenic arteries and veins always ran within a common, inextensible cellular 
sheath, the veins being four or five times larger than the arteries, and in good 
part surrounding the calibre of these ; the parietes of both vessels being so thin 
as to allow of the action of the fluid they contain being reciprocally felt. When 
a too large influx of blood upon the spleen takes place, therefore, the veins 
compress the arteries and impede a farther flow. Dr. Tigri was surprised to find 
that in the horse the veins and arteries ran at some distance from each other : but 
this fact, which seemed at first to oppose his theory, was found to support it. when 
he discovered that nature, besides having given the vena porta? in this animal a 
valve, as first shown by Ernest Weber, has likewise furnished the veins leaving 
the spleen with valves ; so that a regurgitation of blood into the viscus is prevented. 

Dr. Yerga mentioned, that in removing the spleen in cats and dogs, we may 
divide the duplicature of the peritoneum, connecting it to the stomach, without 
tying any of the small vessels into which the arteries and veins are there subdi- 
vided, these not giving rise to any important hemorrhaae. — Brit, For. Med. 
Chirurg. Rev., October 1848, from Gaz. Med. di Milano, 1847, No. 47.' 

2. On the Capillary Circidation. By M. Bourgery.— In addition to the capillary 
or intermediary system of vessels at present admitted by anatomists, and which 
M. Bourgery considers as constituting a mere anastomosis between the arterial 
and venous radicles, unconnected with the vital changes going on in the tissues, 
the author describes a circulation of capilliculi. forming a diverticulum of the gene- 
ral circulation, and pervading more minutely than the capillaries, the ultimate 
elements of every organ. These he looks upon as the proper and special organic 



160 



Progress of the Medical Sciences. 



[Jan. 



circulation, by which, in different organs, the functional changes of secretion, nutri- 
tion, &c, are carried on. The general circulation in itself, does not produce any 
functional changes, but merely preserves unbroken, and independent of the ac- 
tivity of the special circulation, the progressive movement of the blood, which at 
all times passes over in part from the arterial to the venous system, through the 
capillaries; while the capilliculi receive a part of it for elaboration in the special 
tissues to which they are destined. These capilliculi (the size is not stated) are 
impervious to all particles which are not in solution; the blood-corpuscles do not 
pass through them ; nevertheless they may always be traced, varying in disposition 
according to the organ or tissue in which they are situated. For the most part 
they are tolerably uniform in size; but they may be observed, on the one hand, 
to pass into vessels still more minute (not equal to the half, third, or fourth part of 
the diameter of a blood-corpuscle) ; and, on the other, into the ultimate lymphatic 
vessels, which again communicate, by innumerable minute passages, with the 
venous system. 

M. Bourgery conceives that this scheme of the circulation completes, without 
abrogating, that of Harvey and the majority of physiologists. On the one hand, 
it admits a general circulation of the kind described by Harvey, which is perma- 
nent and complete in the circle which it describes; in the other, it asserts an ex- 
tension of this by an infinite number of partial or functional circulations, isolated 
from each other, but connected by means of the general circulation, and in their 
united capacity very much exceeding the latter. These partial circulations are 
special and heterogeneous in their function and distribution, and are only periodi- 
cally active; the only exception to this being in the lung, where the special may 
be considered as subserving a mechanico-chemical function; and being properly 
a function or complement of "the general circulation, is, like impermanent and 
complete. — Comptes Rendus, Sept. 4, 1848. 

[We have endeavoured to express what appears to be the author's meaning, 
although the involved and inexact style in which the conclusions are given, ren- 
ders it, in some instances, not a little difficult to be assured of having done so 
correctly. MM. Magendie, Flourens, Serres, and Milne-Edwards, have been ap- 
pointed to examine into the author's facts. Should they find any reason to sup- 
pose these correct, we would suggest the question, how the change in the colour- 
ing matter of the blood, which apparently does not pass through this new system 
of vessels, is effected; and also, what are the forces which determine the passage 
of the fluids through these vessels ; as it can scarcely be supposed that the force 
of the heart, which is constantly exerted to maintain the general circulation through 
the very free anastomosis of the capillaries, should be the active agent of propulsion 
through this partial and occasionally active system of vessels.] — Monthly Retrosp., 
Dec. 1848. 

3. On the Action of the Pancreatic Fluid. By M. Ch. Bernard. — The author of this 
paper concludes from his experiments that the pancreatic secretion is essential to 
the reception of fatty matters into the system. He found that it immediately 
produces an emulsion, when mixed with oily substances ; a property which is 
not possessed by any other animal fluid. The first action seems purely 
mechanical; but after a time a further change takes place, the fats being decom- 
posed into their fatty acids and glycerine. In this state the bile, which does not 
act on the neutral fats, will readily take them up ; and thus a mixture of bile and 
pancreatic juice, such as is found in the duodenum, has the double power of 
dissolving the neutral fats and the fatty acids. The author has found that if the 
pancreatic ducts be tied, no fatty matters find their way into the chyle. — Brit, 
For. Med.-Chirurg. Rev., October 1848, from Vlnstitut, Mai 3, 1848. 

4. Note on one of the Anomalies of the Right Subclavian Artery, with Absence of 
the Recurrent Nerve of the Right Side. By M. Demarquay. — Anatomists and 
surgeons have remarked with great care, all the anomalies of origin and of 
distribution which the right subclavian artery can present. It is not my object 
here to record them. I desire only to draw attention to a curious fact which 
accompanies one of these anomalies; and to speak of the absence of the right 
recurrent nerve, when the subclavian artery of the same side arises from the left 



1849.] 



Anatomy and Physiology. 



161 



part of the aortic arch, in place of arising from the brachio-cephalic trunk as 
usual. When the right subclavian artery arises from the left part of the aortic 
arch, it directs its course to the right side, either by passing in front of the trachea, 
as Professor Blandin has observed, or behind it, or behind the oesophagus, to 
restore itself to its normal position. In these various circumstances, he (Professor 
Blandin) was curious to know what became of the nerve. Is it alike reflected 
on the artery., or did this anomaly of origin bring with it a modification in the 
nerve ? This it was which I verified for the first time, in 1843 ; in a preparation 
which may be seen in the museum of the school. 

In this case the subclavian artery passed from left to right, and after having 
taken its origin from the left part of the arch of the aorta, passed between the 
cesophagus and the vertebral column, and thus reached the space between the 
scaleni. In this case, which has been recorded in Professor Cruveilhiers u Treat- 
ise on Anatomy," there was absence of the inferior laryngeal nerve. Since 
then, I have had occasion to examine another subject in which the same arterial 
peculiarity existed, and where there was alike absence of the recurrent nerve. 
In these two anomalies, this is the character of the pneumogastric : — it occupies 
the normal position; from its internal part are given off a great number of 
nervous filaments, which are distributed to the larynx, to the inferior part of the 
pharynx, to the trachea, and to the cesophagus. All these nervous filaments, 
destined to replace the inferior laryngeal nerve, pass under the common carotid 
artery; some before this vessel, to distribute themselves to the parts which they 
are destined to innervate. These small nerves which supply the trachea and 
oesophagus with nervous energy, are on the whole alike in volume to those which 
normally furnish the recurrent. As for their length and direction, they are a little 
different, being longer and directed more transversely. The nerves which furnish 
usually the recurrent to the larynx, come, as in the case which occupies us, from 
the pneumogastric ; this latter affords to the level of the larynx, a branch so 
voluminous, that it might be considered a veritable recurrent nerve ; and which 
arrived at the inferior part of the larynx, is in every respect disposed of in the 
same way as the termination of inferior laryngeal nerve, a termination so well 
studied by Professor Blandin. The cardiac nerves furnished ordinarily by the 
recurrent, are given off by the pneumogastric. 

Dr. Demarquay then obsertes, that in a functional point of view this anomaly 
is of no moment, justly remarking that in certain operations, as in tying the 
common carotid, it might occasion great embarrassment to the surgeon, and then 
concludes as follows : — 

Such, then, are four cases where the abnormal origin of the right subclavian 
brings with it an important modification of the nervous vagus. Are these, then, 
accidental cases, or are they the sign of a phenomenon, always persistive when 
the subclavian (right) artery arises from the left part of the aortic arch ;— and 
does this induce absence of the recurrent nerve'? This I would not venture to 
say: further observations must prove it. — Prov. Med. Surg. Journ., Oct. 18, from 
Gaz. Med. de Paris, Sept. 9. 

5. On the Chemical Phenomena manifested by different substances introduced into 
the Organism. By M. Bernard.— The author has performed a very extensive 
series of experiments, of which the conclusions may be stated shortly as follows: 

1. Certain combinations of metals, which take place readily out "of the body, 
and even in the gastric secretions, are prevented from occurring in the blood, and 
other animal fluids, by the affinities of the metal for organic matter. This propo- 
sition was drawn from observations on the reactions of a salt of iron with prus- 
siate of potash. 

2. Certain chemical reactions of the nature of fermentation (e. g. amygdaline 
with emulsine, sugar" with yeast), which commonly do not take place in the sto- 
mach, are easily developed in the blood. 

3. When salts of certain acids, whose affinity for bases is feeble (as the hydro- 
cyanic and the carbonic), are injected into the veins, they are decomposed, and 
the acid is liberated; the decomposition in these cases appearing to take place in 
the capillaries of the lung. 

4. Certain salts (such as the prussiates of potash and the salts of iron) appear 



162 



Progress of the Medical Sciences. 



[Jan. 



to pass in the stomach from a lower to a higher, and in the blood and wine from 
a higher to a lower, state of oxydation. 

[ The extreme interest attaching to M. Bernard's individual experiments, in- 
duces us to give an analysis, in the present and the next Number, of such of them 
as appear to lead directly to the above results.] 

First Series. — After a number of experiments, which were vitiated by the diffi- 
culty of procuring a salt of iron which could be injected in the veins of an animal 
without fatal consequence, M. Bernard discovered that the lactate of iron was 
quite innocuous when used in this way. He then caused a simultaneous injection 
of lactate of peroxide of iron, and of prussiate of potash, to be thrown into differ- 
ent veins in the same animal. The result was surprising. Instead of the blue 
colour, which might have been expected, the blood and the tissues of the body 
experienced no apparent change whatever; the only exception being the pyloric 
extremity of the stomach, where a vivid blue colour was developed. The experi- 
ment was repeated several times, with similar results. In one instance only the 
urine presented a dingy blue colour; in all the experiments, however, a few drops 
of strong sulphuric acid added to the urine produced a copious precipitate of 
Prussian blue. These results were not affected by the acid or alkaline character 
of the urine itself. 

The conclusion from these experiments was, that the double decomposition 
here indicated could only take place in two situations, viz., in the stomach, and 
occasionally to a slight extent in the urine. That the absence of the blue colour 
did not result from the insignificance of the quantities employed, was proved by 
another experiment. Into the veins of one rabbit the ordinary quantity of prus- 
siate of potash in solution was thrown, and after some minutes the animal was 
bled. In another rabbit lactate of iron was injected, and bleeding likewise per- 
formed. On mingling the serum derived from these two rabbits, no reaction took 
place; nevertheless the one serum was easily proved to contain iron, and the 
other prussiate of potash. On adding now to the mixed serum of the two animals 
a few drops of sulphuric acid, the blue precipitate was instantly produced. The 
action of the urine of the two rabbits when mingled, was precisely similar to that 
of the serum. It was different, however, with the gastric fluid. On washing the 
coats of the stomach in the two animals, acid liquids were procured, which, on 
being mingled, gave rise to a blue colour immediately. 

That this difference between the gastric and the other fluids was not due solely 
to acidity, was shown by the fact, that the urine presented the same phenomena, 
whether acid or alkaline, as above stated. 

Having determined these facts, M. Bernard next proceeded to try the effect of 
the direct addition of the salt of iron, and afterwards of the prussiate of potash, to 
serum, urine, and gastric juice. In the first two he found that, except in the case 
where an acid was added, or large quantities of the re-agents used, there was no 
blue precipitate, while in the last the blue colour always appeared. When, how- 
ever, the precipitate or potash was added first to the fluids, and afterwards the 
iron salt, the blue colour was immediately produced in the whole. 

M. Bernard accordingly concluded, that from the attraction of iron for animal 
substances, it is prevented from developing its usual relations with prussiate of 
potash, when both these substances are injected into the blood ; but that if a strong 
acid be added to animal matter containing these salts, this affinity for the animal 
matter is destroyed, and the several chemical relations are established. This 
does not take place, however, on the addition of phosphoric, acetic, or lactic acids. 

The peculiarity of the gastric juice in these experiments is explained by the 
author, on the ground of the small quantity of organic matter in it being less than 
any other secretion in the body. [May not the existence of free muriatic acid be 
a more valid explanation?] 

The tendency of iron to combine with the tissues, is further illustrated by M. 
Bernard in three experiments. In the first, a solution of lactate of iron was in- 
troduced into the cellular tissue of the neck, and a similar quantity of solution of 
prussiate of potash into the right thigh. A blue colour soon became developed 
in the former situation, while the thigh retained its natural colour. In the second 
experiment, the salt of iron was introduced into the thigh, and prussiate of potash 
was injected into the veins; the blue colour became developed in the thigh. In 



1849.] 



Anatomy and Physiology. 



163 



the third experiment, the salt of potash was introduced into the cellular tissue, 
and the iron-salt into the veins. In this case there was no blue colour developed. 

It is obvious from these experiments, that the prussiate of potash circulates 
rapidly in the general mass of the blood, even when introduced into the system 
by a wound in the integuments; while the iron seizes on the tissue with which it 
is placed in contact, from which it is very sparingly absorbed into the circulation. 
Thus the mixture of the two salts is not effected, except at the point of introduc- 
tion of the iron. 

Second Series. — The author next proceeded to determine if the blood presented 
any obstacle to the establishment of certain catalytic reactions, which take place 
with facility external to the organism. The action of emulsine on amygdaline is 
favourable "for this purpose, inasmuch as a highly poisonous substance is instantly 
generated by their union. The experiments of M. Bernard satisfactorily, deter- 
mine, that the injection of these substances into the circulation, simultaneously, or 
at a short interval, causes death, with the usual symptoms of poisoning by prus- 
sic acid, and with the evolution of a strong smell in the breath of oil of bitter 
almonds. The injection of either of the substances separately, on the contrary ? 
gave rise to no fatal results. 

The action of diastase on starch in the blood might naturally be expected to be 
a good subject of experiment. But the serum of the blood has the singular pro- 
perty of producing the transformation of starch into sugar; hence experiments on 
this head were not instituted. 

The transformation of sugar into alcohol, by means of yeast, was the next sub- 
ject of experiment. In two animals (a dog and a rabbit), cane sugar and yeast 
were simultaneously introduced into the circulation in considerable quantity. Both 
animals died. The urine of the rabbit alone was examined; it remained quite 
free of sugar (which, under ordinary circumstances, passes with great ease into 
the urine). The symptoms in both animals were those of a marked typhoid con- 
dition, with fever and extreme debility; the rabbit died in less than twenty-four 
hours, the dog on the third day. The morbid changes were, in both animals, in- 
jection, ecchymosis, ulceration of the stomach, ecchymotic patches in the small 
intestine, and a dark imperfectly coagulated state of the blood. In both cases (a 
sufficiently singular fact) the pancreas was diseased, the orifice of its ducts being 
tumid and red ; its substance in the rabbit red and inflamed ; in the dog, the seat 
of numerous small abscesses. These facts appear to indicate a special poisonous 
action, exercised by the alcoholic fermentation upon the animal organization; and 
also to prove that the change of sugar into alcohol may occur within the circu- 
lation. 

Third Series. — The rapidly fatal effect of cyanuret of mercury, when introduced 
into the stomach, is readily explained by the action of the gastric juice, which, 
even externally to the body, decomposes it, setting free hydrocyanic acid. The 
action of this salt, when introduced into the veins, on the contrary, cannot be ex- 
plained by the action of the blood upon it; as, out of the body, no decomposition 
takes place. Nevertheless, on injecting the cyanuret of potassium into the veins 
of an animal, a poisonous effect, similar to that of prussic acid, is produced; and 
the odour of prussic acid is exhaled from all the tissues. 

Where, then, does this decomposition take place? As all the acid fluids of the 
body present a reaction similar to the gastric juice, M. Bernard performed the fol- 
lowing experiment, to exclude the possibility of the decomposition taking place 
in the stomach or urinary passages. The stomach, kidneys, and bladder, were 
removed from a live dog. A solution of cyanuret of mercury was then injected by 
the crural vein; in half a minute the animal began to respire with difficulty, and 
died soon after, convulsed. All the tissues were impregnated with the odour of 
prussic acid ; yet in no place could an acid fluid be found. [Were the contents of 
the caecum examined? It appears to us that their well-known acidity forms an 
objection to this experiment.] 

With the view of cjiscovering whether this reaction took place in the systemic 
capillaries, the author now isolated the thigh of a dog from all communication 
with the rest of the body, leaving only the artery and vein entire. He then in- 
jected by the artery a sufficient quantity of cyanuret of mercury, and shortly after- 
wards drew blood from the vein. The blood contained abundance of the salt, but 
no trace of prussic acid; the tissues of the thigh were in a similar condition. 



164 



Progress of the Medical Sciences. 



[Jan. 



From this experiment, M. Bernard judges that the systemic circulation is not en- 
gaged in the decomposition of the cyanurets; he therefore, by way of exclusion, 
ascribes this decomposition to the pulmonic circulation. 

Certain bicarbonates are decomposed in the blood when passing the capillaries 
of the lung. Thus, if a large quantity of solution of bicarbonate of soda be in- 
jected into the veins of a rabbit, the animal dies suddenly, and, on dissection, 
there is found air in the division of the pulmonary artery, and sometimes even 
in the ventricles of the heart. The lungs also are emphysematous and distended. 
These results are not produced if the same salts are intioduced gradually. 

Fourth Series. — The experiments of this series are not so important as to require 
detailed notice; they consisted simply of an examination into the effects of differ- 
ent animal fluids, on the state of oxydation of the ferrocyanurets of potassium, 
and the salts of iron. — Monthly Journ. Med., fyc. July and Aug., 1848 • from Archives 
Generates de Medecine, Jan. and Feb., 1848. 



ORGANIC CHEMISTRY. 

6. On the Acidity and Alkalinity of certain of the Human Fluids in the state of Health 
and Disease. By M. Andral.— In their physiological conditions, each of the 
humours of the body presents a certain degree of acidhy or alkalinity; and the 
spontaneous transformation of a naturally acid fluid into an alkaline one, or vice 
versa, never takes place in the healthy organism. The utmost that can occur in 
this respect, is the rendering the fluid temporarily neutral by great dilution, as in 
the case of excessive perspiration — the water then being abstracted from the blood 
in larger proportion than the other principles. However this may be in health, 
the opinion is very generally entertained that in disease such chemical change 
in the humours does often take place; and the object of this paper is to investi- 
gate its accuracy. 

Of all the fluids of the economy, the serum of the blood is the most decidedly 
alkaline; and whatever the nature of the disease or its duration, in- which M. 
Andral has examined this fluid, he has never found the intensity of this reaction 
sensibly vary. Vogel quotes a case of metro-peritonitis from Scherer, in which, 
the serum of the blood is said to be perfectly neutral, but adds, that he himself 
had never met with anything similar. If blood is examined after death, any 
acidity then found is the result of decomposition, and not the effect of disease. 
In examining the condition of fluids formed from the blood, it should be borne in 
mind that upon the same surfaces liquids possessed of different reactions may be 
found; so that the accidental predominance of one of these fluids may easily be 
mistaken for a change in the reaction of another. Thus the sweat is acid, but the 
sebaceous matter is alkaline. In the very various conditions in health and disease 
under which M. Andral has examined the sweat, he has found it generally acid, 
sometimes from dilution neutral, never alkaline; but at the same time, at some 
parts of the skin, where sebaceous follicles abound, as the axilla and other hairy 
parts, an alkaline reaction may exist. It is evident, then, that the sweat is not a 
simple escape of the serum of the blood, charged with certain of its principles, 
for then it would be alkaline; and if the skin be irritated by blisters and the like, 
the fluid consequently effused will be found decidedly alkaline. So is the fluid 
found in herpes, eczema, pemphigus, &c., vesicular diseases preceded by more 
or less congestion of the skin ; and it is remarkable that the contents of sudamina, 
which unlike these are preceded by no congestion, are acid, being also destitute 
of albumen, which is found in the others. Although sudamina are usually accom- 
panied by excessive sweating, cases of typhoid fever are sometimes* met with 
where this is not the case. 

Still more remarkable is the difference of the reactions of the various fluids 
found on mucous membranes, giving rise to considerable chance of error. Through- 
out their whole extent, they furnish, like the skin, an acid principle, which exists 
in the transparent fluid, destitute of globules, which they normally separate from 
the blood ; but when this fluid is replaced by one of an opaque appearance and 
containing globules, secreted under the influence of acute or chronic inflamma- 



1849.] 



Organic Chemistry. 



165 



tion, the reaction becomes decidedly alkaline. Few animal fluids are so strongly 
alkaline as that furnished in coryza; and in bronchitis the acid and alkaline are 
not unfrequently found together, and yet remaining quite distinct in their trans- 
parent and opaque forms, The mucous membrane of the month and tongue, too, 
offers varieties of condition. Examined in the morning, before food is taken, in 
the vast majority of cases, the fluid covering it is acid, but examined later in the 
day this is found to be alkaline. In the first case, it is due to the presence of the 
mucus ■ in the latter to that of the saliva. The acidity of the mouth is then no 
indication of a morbid condition of the stomach, occurring as it does in the 
healthiest persons, and in every variety of disease, and being distinct in propor- 
tion to the length of time food has been abstained from, and the secretion of the 
salivary glands has remained unexcited. The mucous membrane of the stomach, 
examined after death, generally furnishes an acid, sometimes a neutral, but never 
an alkaline reaction; and this whether it yet contains the remains of food, or 
whether digestion has been long suspended. How are we to reconcile this with 
the results of experiments which declare the fluids of the organ to be alkaline, 
save when stimulated by the presence of food or foreign bodies'? This is not the 
case in man: for in the most opposite forms of disease the author has found 
acidity ; and the great majority of matters rejected during life manifest the acid 
reaction. It is not rare to find this also in the duodenum and upper portions of 
small intestine; although these are often rendered alkaline by the arrival of the 
fluids from the liver and pancreas. Throughout the large intestine there is 
always marked alkalinity. The tears and saliva have always been found by M. 
Andral alkaline; and he believes that when this latter fluid has been said to be 
otherwise, that of the mucous membrane has been mistaken for it. Thus, in the 
very cases furnishing an acid reaction, if we. by means of a sapid body, excite 
the flow of the saliva, we immediately find this alkaline. " And thus falls to the 
ground one of the principal arguments which has been adduced in support of the 
theory which regards glucosuria as resulting from the acidification of the blood or 
other humours of the economy." 

In a state of health, mine which has not remained too long in the bladder, and 
is examined soon after voiding, is always acid, although such acidity may 
become much enfeebled, or even neutralized, if very abundant drinks be taken 
without corresponding diaphoresis. Circumstances may render the urine tem- 
porarily alkaline, as the taking alkalies, or the prolonged use of exclusively 
herbivorous aliment. The privation of food, however long, does not remove the 
acidity of the urine; but it is a curious fact, that in some convalescents we find 
the urine become temporarily alkaline when they commence a better diet. Nor 
does disease render the urine alkaline. Multiplied as have been the author's 
observations upon this point, he has never met with a case in which the urine, 
from the influence of the disease itself, left the kidneys in an alkaline state; and 
he feels convinced that the statements which have been made to the contrary are 
founded in error. It has been said that diseases of the spinal marrow have this 
effect; but, in fact, the urine never becomes alkaline in these, until the mucous 
membrane of the bladder is diseased. It is not then an alteration of secretion, 
but a purely chemical one; the urine becoming decomposed and ammoniacal, 
from coming in contact with pus and other morbid products. Pus, whatever its 
source, is always alkaline, consisting as it does of the serum of the blood, amidst 
which special globules are developed ; and this, as well as other morbid secretions, 
never becomes acid, except after long exposure to the air. 

The immutability of the secretion of the acid and alkaline principles of the 
animal fluids is then a law of both their physiological and pathological condi- 
tions; and it must be a very important one, seeing that it persists without any 
exception, save one of a very temporary character, in respect to the influence of 
alimentary substances in the urine. — Brit, For. Med.-Chirurg. Rev., October 
1848, from Gaz. Medicate. 1848, No. 28. 

7. On certain forms of Alkaline Urine. By Dr. G. Owen Rees.— -In a case of 
extrophy of the urinary bladder, Di\ Rees had an opportunity of observing the 
condition of the urinary secretion before and after contact with the mucous mem- 
brane of the bladder. He found that, when tested as it flowed from the extrerai* 



166 



Progress of the Medical Sciences. 



[Jan. 



ties of the ureters, it had a normally acid reaction ; but that as it trickled, drop by- 
drop, over the mucous membrane of the bladder, it became rapidly alkaline, from 
the admixture of a copious alkaline mucus which was secreted from the exposed 
membrane. Dr. Rees conceives the alkaline secretion to be thrown out for the 
protection of the irritable membrane of the bladder, and thinks that a certain 
number of cases of alkaline urine are due to the stimulating effect of an originally 
acid secretion upon the genito-urinary mucous membrane, which from some 
cause, secretes an excessive quantity of alkaline fluid. He explains the effect of 
alkaline remedies, in some instances, in removing the alkalinity of the urine, on 
the supposition that the urine as secreted, being reduced nearly to the neutral con- 
dition, is thereby deprived of all irritating properties, and is enabled to pass over 
the genito-urinary mucous membrane without exciting any alkaline discharge to 
affect its properties secondarily. The distinction between such cases of alkaline 
urine and others, is only to be effected by attention to the history and symptoms, 
and by chemical and microscopical examination of the urine. — Medical Gazette, 
April,' 1848. 

8. Characters of the Urine in Brightfs Disease. By A. B. Garrod, M.D. — In the 
early stages, or acute form of this disease, albumen appears to be thrown out, in 
addition to the ordinary urinary constituents, and with it we frequently find the 
colouring principles or globules of the blood. Hence the specific gravity is usually 
high, the amount of secretion diminished, and frequently a deposit of urates takes 
place on the cooling of the fluid. Even in this stage, however, the urea is defi- 
cient; at least, the total amount eliminated in the twenty-four hours; and this 
principle is found to be retained in the blood. As the disease advances and be- 
comes chronic, the character of the urinary secretion greatly alters, the albumen 
often becomes less in amount, and the total quantity of solids is also much dimin- 
ished, and hence the urine is of low specific gravity, paler in colour, and generally 
slightly opaline, an appearance due to the suspension of certain insoluble matters 
consisting of the cylindrical lining of the urinary tubules, fat globules, epithelium 
scales, &c: these, by standing, form a light flocculent deposit; the persistence 
of these bodies in the urine may be almost regarded as pathognomonic of the 
disease; although temporarily, they may occur in any affection in which there 
exists an irritated or congested condition of the kidneys. The quantity of urea 
excreted in the twenty-four hours is generally very deficient, and its relative 
amount, compared with the total solids, is also much lessened. It is in these 
cases that we find abundance of urea in the blood and effused fluids, the kidneys 
having lost their power of eliminating this body. The amount of watery excre- 
tion may be either large or small; sometimes it considerably exceeds the normal 
average, at others it falls far short of it, and in the last stages the urinary secretion 
may be totally suppressed. In the following table two analyses are seen, taken 
from Becquerel, showing the amount and characters of the urine in two cases of 
the disease. 

i. ii. 

Amount of urine in twenty-four hours 28 oz. - - 78 oz. 
Specific gravity - - - 1016.3 - - 1008.4 



Water .... 965.0 - - 986.3 

Urea - - - - 1 1.6 > - 1.8 

Uric acid - - - 0.3 0.2 

Extractives - - - - 4.6 - 5.5 

fixed salts - - - 6.6 - 2.9 

Albumen - - - 11.9 - 3.4 



1000.0 1000 

Albumen is stated occasionally to occur in the urine after the ingestion of cer- 
tain articles of diet, as pastry; also after the administration of mercury, and the 
application of blisters of cantharides. Of the power of the first-named cause I 
have never seen an example, and that mercury by no means frequently produces 
such a state of urine I have had ample proof, although, in Bright's disease, saliva- 



1849.] 



Materia Medica and Pharmacy, 



167 



tion is often readily produced by this mineral, which may hare led to the opinion 
of its having caused the presence of the albumen in the fluid. The application 
of blisters appears sometimes to cause albuminous urine, probably from irritating 
the kidneys, and we know that hematuria also is at times thus produced. — Lancet 3 
Dec. 2d, 1848. 



MATERIA MEDICA AND PHARMACY. 

9. Action of Calomel on the Liver. By M. Michea. — When calomel is admin- 
istered in purgative doses, the stools become more liquid, and at the same time 
acquire a characteristic green colour. This green colour is usually, at least by 
English practitioners, held to indicate the presence of bile, and the experiments 
of our author tend to show that the opinion is well founded. Calomel stools have 
been analysed by Golding Bird {Med. Gaz., Sept. 1845), who found only slight 
traces of bile: and by Siebert of Erlangen, who failed to obtain any indication of 
that secretion. Dr. Bird concluded from his experiments, that the green colour is 
due to an altered condition of the colouring matter of the blood. 

M. Michea has examined the feces under four different conditions: — 

1. Feces passed by a healthy individual, no drug having been administered. — 
In six specimens no bile Was found. 

2. Green stools rendered by individuals suffering from gastro-intestinal irritation, 
no drug having been administered. — The presence of bile was indicated in one 
only of three cases examined. 

3. Calomel stools. This drug was exhibited to eight individuals, and the alvine 
dejections presented a green colour in four. In these the presence of bile was 
readily demonstrated. These stools showed also the presence of a large quantity 
of albumen, which the author supposes to be derived from the bile. 

4. Stools obtained by the exhibition of saline and other non-mercurial purgatives. 
— These never or very rarely present the green colour or the viscosity peculiar to 
calomel stools. Five specimens were examined; neither biliverdiri nor albumen 
was found. 

The author prefers the nitric acid as a test for bile. Added to an animal liquid 
containing this secretion, a characteristic reaction ensues; the fluid becomes first 
green, then bluish-violet, and finally assumes a red colour. These changes occur 
within the space of a few seconds. 

From these experiments it may be concluded that calomel stools contain an ex- 
cess of bile, as nitric acid reveals in them the existence of two principles of that 
secretion, biliverdin and albumen. — Monthly Retrospect, Dec. 1848, from V Union 
Medicate, Oct. 21 and 23, 1848. 

10. An Effect of Opium, upon which sufficient stress has not hitherto been laid. — 
Opium increases the circulation of the skin, and diminishes that of the mucous 
membranes. A person who has taken a full dose of opium at night, will, amongst 
its other effects, feel himself the warmer for at least twenty-four hours afterwards. 
I am acquainted with a gentleman who has met with considerable success in his 
practice on indolent old ulcers, and one part of his treatment consists in his giving 
his patient a grain of opium thrice daily ; this is done upon the principle of stimu- 
lating the capillary circulation of the part. In that form of deafness which is at- 
tended with tinnitus, and appears to consist in a congested state of the mucous 
membrane of the Eustachian tube and tympanum, I have often successfully pre- 
scribed opium with a view of increasing the cutaneous circulation, and diminish- 
ing that of the mucous membranes. 

An old lady suffered from a severe attack of influenza, the poison of which 
seemed principally to operate upon the Schneiderian and bronchial mucous mem- 
branes. For four years afterwards she constantly suffered from an obstruction in 
both nostrils, attended with so profuse a secretion of thin mucous fluid, as to oblige 
her to use four or five handkerchiefs in the course of a day, and the least exposure 
of the lungs or surface to a cold atmosphere, brought on an asthmatic attack, which 
•was accompanied with a copious frothy expectoration. Though she could smell 



168 



Progress of the Medical Sciences. 



[Jan. 



nothing which was presented to her nostrils, she was troubled with an offensive 
putrid odour, which she imagined was always present, whilst the sense of taste 
had become so obtuse, that she could neither distinguish tea from water, nor salt 
from soda. I had been acquainted with her for a long time, and had frequently 
prescribed various remedies without success, as a great many other practitioners 
also had done. The mucous membrane of both nostrils was swelled, redder than 
natural, and so acutely sensitive, lhat she could not bear the slightest touch with 
my probe. These symptoms and appearances might have induced me to the 
opinion of the case being one of malignant polypus; but though the disease had 
existed so long without any amendment, it had, on the other hand, made no 
advance ; and besides this circumstance, the history of the case, and the co-exist- 
ence of the thoracic affection, were not in favour of this supposition. One morn- 
ing, whilst sitting near her, and witnessing the constant annoyance from which 
she was suffering, I remembered that, whilst I was attending her for an acute dis- 
ease, by which she was confined to her bed, she mentioned that her head and 
chest symptoms had suddenly become much better, for she had barely wet a 
single handkerchief, and fancied she had perceived the savoury odour of a stew, 
which was being prepared in the kitchen. I paid no attention to this circumstance 
at the time, especially as, a few days later, I noticed that she again seemed as 
bad as ever. But now, and it was at least a twelvemonth afterwards, a bright 
thought struck me; I remembered that, at the time she spoke of this amendment, 
she was taking opium in considerable quantities, for a spasmodic pain in the 
bowels. My opinions on the effects of opium, which I have above detailed, were 
already formed, and I determined upon having recourse to it in this instance. I 
laughingly told her that a brilliant idea had come into my head, and that I now 
knew what would give her relief. The good old soul shook her head doubtingly. 
and said that she would give me fifty pounds if it did. (She never paid me, if 
she meant it.) Desirous of concealing the nature of the remedy, I prescribed the 
Pilula Styracis Composita, in five grain doses, every night at bed-time. Some 
improvement was apparent in the course of a very few days, and it became con- 
tinually progressive. In two months she ceased to wet more than a single hand- 
kerchief daily, and had even some return of the sense of smell and taste, whilst 
she had now become comparatively indifferent to a low atmospheric temperature; 
for although during the whole of the previous winters she had been obliged to 
confine herself to one room, or to move through the passages with a shawl, or a 
respirator, before her mouth, during the next cold season she wandered about the 
house, without finding any precaution necessary. She always had expressed 
herself with extreme confidence of the benefit she had received, and, as a proof 
of her faith, T may mention the great glee with which, during her last illness, she 
received the intelligence that I allowed her to have one of her old pills ; those pills, 
she believed, would cure every malady. She died of another complaint, seven 
months after the commencement of this treatment, but I believe that the improve- 
ment in her head and chest symptoms had been progressive to the last. 

Opium-eaters generally complain of feeling cold and shrunk up, when they are 
deprived of their habitual stimulus. These effects of opium on the mucous mem- 
brane are well illustrated in the following passage, which is taken from the " Con- ' 
fessions of an English Opium-Eater — 

" I must mention one symptom which never failed to accompany any attempt 
to renounce opium,— viz., violent sternutation. This now became exceedingly 
troublesome, sometimes lasting for two hours at a time, and recurring at least two 
or three times a day. It is remarkable, also, that during the whole period of years 
through which I had taken opium, I had never once caught cold, not even the 
slightest cough, but now a violent cold attacked me, and a cough soon after." — 
Prov. Med. and Surg. Journ., Nov. 15, 1848. 

11. Phy siological Action of the Iodide of Potassium. By MM. Boys de Loury and 
Costilhes. — In an article on the therapeutic action of different medicines used at 
St. Lazare, in the treatment of syphilis, these gentlemen remark that they have 
paid particular attention to the effects produced by this medicine, and that they 
oecur in the following order : — 

1. Action on the Intestinal Canal. — The first day, the dose being 0-75 gramme 



1849.] 



Materia Medica and Pharmacy. 



169 



(10 to 12 grs.), slight pain and heaviness in the stomach: the pain is, however, 
not always present; the appetite is usually increased; it is remarkable how soon 
after the taking of the iodide the desire for food arises. 

The following days these symptoms diminish or disappear. The second day, 
the dose being 1-00 gramme (upwards of 15 grs.), heaviness of the head, colic, 
and diarrhoea. 

2. On the Urinary Secretion. — This is more abundant the first day, that is, the 
patient passes* more than he drinks. This symptom is almost constant. The urine 
is clear and transparent— the patients urinate more by night than by day. Some- 
times, however, the urine is not increased. 

3. Eruption. — The most frequent is the pustule of acne, which shows itself from 
the end of the first to the second day. It most frequently occurs on the face; it 
does not usually last as long as the treatment, that is, it disappears in 15 or 20 
days. Ecthyma more rarely. Neither papular erythema nor purpura hemoirhagica 
was observed; in one case an eczema impetiginoides was seen. 

4. Pruritus very seldom observed. 

5. Conjunctivitis. — The conjunctiva was sometimes influenced when the iodide 
was given in doses of 1 to 2 grms. Both conjunctivas may become inflamed. It 
principally occurred during the first days of the use of the medicine, and was cha- 
racterized by general vascularity and chemosis. 

6. Menstruation. — Although this medicine is spoken of by most authors as an 
emmenagogue, they often remarked a decrease in the quantity of the menstrual 
fluid. Once the discharge re-appeared a w T eek after the menstrual period; but 
this may have been only a coincidence. 

7. Discharges from the uterine cavity were not perceptibly increased. 

8. As invariable and immediate effects, the authors never once failed to see the 
decrease or suspension of the pains of the bones after the first or second day of 
treatment. No other antisyphiiitic agent possesses so prompt and constant an 
action. 

9. Salivation. — This is a rare symptom in women; it was seen only once. 3V1. 
Ricord observed it more frequently, perhaps, because he gave the medicine in 
larger doses. The saliva remained thin, the mucous membrane of the mouth un- 
inflamed and unaltered; the salivary glands not swollen — a true hypersecretion, 
without peculiar smell. 

10. Effects on the Circulation — none. 

11. Accidents produced by the Iodide. — The authors object to giving the iodide in 
such large doses as some physicians administer it. M. Biechy relates two cases 
in which serious accidents were produced. In the first, the patient being bene- 
fited by doses of three-fourths of a grain, gradually increased to fifteen grains, 
thought by doubling the dose to double the advantage received. The first three 
days he sufFered from general uneasiness and intense headache; the fourth day 
he was affected in his lower limbs, his sight disturbed, and his hearing almost 
gone; on trying to walk, his legs gave way under him, and his arms had lost all 
power. Finally, having taken a few steps, he fell unconscious; on coming to 
himself, he remained in a state of languor and weakness, which did not disappear 
for several days after the suspension of the medicine. In the second case, death 
ensued; but it was doubtful if it could be attributed to the iodide. — Month. Journ , 
July, 1848, from Gaz. Med. de Paris. 

12. Action of Chloroform. — M. Malgaigne has made to the French Academy of 
Medicine a very interesting report on chloroform. The following are his conclu- 
sions : — 

1. Chloroform is a most energetic substance, which maybe classed with poi- 
sons, and should be only used by experienced persons. 2. It is liable to cause 
irritation of the air passages, and should be employed with reserve in persons suf- 
fering from the lungs or heart. 3. Chloroform possesses a special toxic action, 
which has been profited by, and is carried as far as the production of insensibility, 
but which may occasion death if improperly prolonged. 4. Certain modes of ex- 
hibition increase the perils inherent to chloroform ; thus asphyxia may be brought 
on, if the aneesthetic vapours are not sufficiently mixed with air, or if respiration 
is not performed with freedom. 5. All these dangers may be obviated if the sur- 



170 



Progress of the Medical Sciences. 



[Jan. 



geon, in the first place, ascertains that the respiratory organs and the circulating 
system are sound, if a sufficient quantity of air is admitted into the lungs, together 
with the chloroform ; and, finally, if the inhalation is suspended immediately upon 
the production of unconsciousness. 

M. Amussat maintained that although a free ingress of air took place into the 
lungs at the same time with chloroform vapours, the colour of the arterial blood 
became darker as soon as the insensibility was produced. M. A. observes that 
the effects of ether or chloroform were to be particularly dreaded when patients 
had lost much blood. — Med. Times, Nov. 25. 

These conclusions of M. Malgaigne have been attacked by M. Guerin, who 
proposed to substitute for them the following:— 

1. That chloroform, a most energetic agent, was susceptible, in experienced 
hands, of rendering signal service, but exhibited in expressive doses, or for 
too long a time, or by improper methods, it might become a direct cause of death. 

2. That circumstances, peculiar conditions existed, not yet altogether pointed 
out with precision, but of which certain instances demonstrated peremptorily the 
possibility, which increased the toxic properties of chloroform, and which neces- 
sitated the greatest caution in its use. 

3. That in M. Gorre's case, it was the opinion of the Academy that chloroform 
had probably occasioned death, although that agent had been employed in a dose 
and in a manner which experiment had almost universally shown to be innocu- 
ous; and that the rapidity, and exceptional intensity of the intoxication, had been 
in that instance favoured by individual circumstances, which the surgeon could 
not possibly foresee. — Med. Times, Dec. 2, 1848. 

13. Administration of Mercury in small Doses. — Mr. Hancock stated to the Medical 
Society of London that he had adopted the plan recommended by some French 
surgeons of giving calomel in very small doses, — a twentieth part of a grain every 
hour day and night, until the specific effect of the medicine was produced, — with 
two patients in Charing cross Hospital, both of whom had been admitted with in- 
flammation of the testicle, consequent upon gonorrhoea. In one case, he gave a 
twentieth of a grain of calomel every hour; in the other, a twentieth of a grain 
every three hours. In the first case, the patient was salivated in thirty-six hours; 
in the second case, in forty-eight hours. The advantage of this mode of produc- 
ing ptyalism was, that the effect was milder and more controllable than where 
larger doses were administered; the bowels were also unaffected. The mode of 
its administration was as follows: — Calomel, one grain; confection of opium, a 
scruple ; divide in twenty pills—one every hour. In the cases related, the effects 
of this medicine were most decided. — Lancet, Oct. 7, 1848. 

14. Narcotic Principle in Indian Hemp, a Peculiar Resin. By Messrs. T. & H. 
Smith, Edinburgh. — The researches of these chemists show that the remarkable 
action of Indian hemp on the animal economy depends on the presence of a 
particular resin, which is soluble in alcohol, and from which it is precipitated by 
water in the form of a white powdery substance. 

This resin, obtained by means of a process described by the authors, is of, a 
yellowish-brown colour. It has a hot, pungent, balsamic taste. Heated on a plate 
of platinum, it melts and burns away without leaving any residuum, diffusing a 
strong aromatic odour. 

Messrs. Smith found, by experiments made on themselves, that this substance 
possesses the soothing and hypnotic properties of morphia. In the dose of two- 
thirds of one grain English, it is a powerful narcotic ; in the dose of one grain, it pro- 
duces complete intoxication. 

Under its influence the pupil is contracted. Its action is very persistent; but it 
does not appear, like opium, to have the inconvenience of producing constipation. 

To this resin, of which the plant contains from six to seven percent., the various 
preparations used in the East, as haschisch, &c, owe their well-known proper- 
ties. — Edin. Med. and Surg. Journ., Oct. 1848, from Pharmaceutical Journal. 

15. Camphor and Chloroform Mixture. By T. andH. Smith. {Monthly Journ. 
Retrosp. of the Medical Sciences, Nov. 1848.) — There is great difficulty, or rather 



1849.] 



Materia Medica and Pharmacy. 



171 



an utter impossibility of administering camphor in a state of solution in doses of 
sufficient potency in some cases. The form of pill, the only mode of giving 
large doses of this medicine, is objectionable in many cases, and in others 
altogether inadmissible. The camphor, being merely in a state of mechanical 
division, on being set free in the stomach, from its extreme lightness quickly 
separates and floats about, thus producing in many cases much local irritation in 
that organ, instead of soothing or arousing the general system. 

Messrs. T. & H. Smith, Chemists of Edinburgh, give a formula for exhibiting 
camphor in doses of almost any amount of strength — certainly as laTge as any 
case can require — and that in a state of perfect solution: thereby allowing of a 
nice adaptation of the dose to the circumstances of each case. 

The formula is as follows : — Three drachms of solid camphor are dissolved in 
one fluid drachm of chloroform. This is, perhaps, one of the most remarkable 
cases of solution the whole range of chemistry presents to us. The solution is 
most rapid and complete, and the bulk of the liquid is now increased from one to 
fully four fluid drachms. This solution rubbed up with the yelk of one fresh egg, 
may be formed into an extremely elegant emulsion by the addition of water, 
without the slightest separation of the camphor or chloroform ; in fact, no separa- 
tion of any kind takes place. If to the proportions given above as much water 
be added as to make a four-ounce mixture, each teaspoonful of the mixture when 
formed will contain about five and a half grains of camphor, and about two 
minims of chloroform. The capability of the formula being varied, so that 
either the camphor or chloroform may constitute the predominating ingredient, 
must be quite obvious. This mixture can be administered in any ordinary 
vehicle, such as water, without the occurrence of any separation ; indeed, the 
mixture is as readily and completely effected as cream with tea or coffee. We 
have tried the effect of several medicinal substances on the mixture. With none 
of them has any separation been caused. 

A weak saline solution, composed of common salt, phosphate of soda, and an 
alkaline carbonate, mixed readily, as well as a solution of muriate of morphia and 
sulphate of zinc. With the volatile alkali and acid liquids — such as a weak solu- 
tion of acetic and muriatic acids — the mixture seems to become more intimate 
and stable. The mixture with ammonia has stood since its preparation — now fully 
a week — without any separation. With water alone, however, the chloroform 
solution of camphor separates in a few days, but they readily unite again when 
slightly agitated. The solution of camphor in chloroform, although insoluble in 
water alone, appears in this mixture to be in as complete a state of mixture as the 
butter in milk when newly drawn from the cow. 

The therapeutic value of the formula remains to be ascertained. 

16. Supposed Test for Cod Liver Oil. By Mr. Hockin. — Mixing together on a porce- 
lain slab four parts of genuine cod-liver oil, and one part of strong sulphuric acid, 
and stirring with a glass rod, a beautiful and rich violet colour, similar to that of the 
fumes of iodine, is produced, which in a few instances passes gradually into a 
dirty brown ; the altered portion of the oil separating in regularly shaped patches 
from that out of reach of the acid. This characteristic is not possessed by either 
olive, almond, seal, whale, or fine sperm oil ; nor, Mr. Hockin believes, by any 
other fat oil. The reaction varies in appearance from a delicate fawn to a dark 
caramel. — Med. Times, Sept. 23. 

[We have tried this test and found the results to correspond with the statement 
of Mr. H. But it is stated in the Pharmaceutical Journal, that this test will merely 
indicate the presence of cod-liver oil; but does not afford the means of ascertain- 
ing whether other oils be mixed with it or not, and that with mixed oils in 
various proportions the result is so equivocal as to be calculated to mislead except in 
the extreme case of no cod-liver oil being present. It also gives no indication 
of the quality of the oil, as some of the worst samples, not fiffor sale, exhibited 
the purple appearance as decidedly as the best genuine oil.] 



172 



Progress of the Medical Sciences. 



[Jan. 



MEDICAL PATHOLOGY AND THERAPEUTICS AND PRACTICAL 

MEDICINE. 

17. On the Anatomy of the Enlarged TJiyroid Gland in Bronchocele. By Professor 
Ecker, of Basle. — Of this very important communication, we can only give the 
principal heads. The author distinguishes two principal varieties of bronchocele, 
which may occur separately, but are frequently combined. These are (a) struma 
vasculosa, in which the vessels are chiefly concerned; and (b) struma glandulosa, 
which consists essentially in alterations of the closed glandular vesicles. 

a. The first of these seems to originate in simple congestion, which may be 
only temporary ; but if it becomes permanent, the capillaries and smaller arteries 
become aneurismatic and varicose, undergoing dilatation to three or four times 
their usual diameter. Sometimes the dilated portions seem to become detached 
from the rest of the vessel, and to form cysts containing blood ; a mass of altered 
nearly colourless blood-corpuscles, adherent to each other, being often found in 
their interior. When the disorder has advanced to this stage, the gland-vesicles 
have usually disappeared. Of these changes, hemorrhage and exudation are fre- 
quent results. When blood is extravasated, it frequently becomes surrounded by 
a sort of cyst, as in apoplectic extravasations in the brain, and undergoes changes 
similar to those occurring in an apoplectic clot: this condition forms one variety 
of what has been termed Struma cystica, which depends (as we shall see) on va- 
rious pathological changes. Another variety is the result of exudations, which 
are sometimes diffused, and sometimes collected in masses which become en- 
cysted. In the midst of these exudations, the components of which are generally 
primitive fibres and elementary granules, with blood-corpuscles, we are assured 
by Professor Ecker, that new vesicles or cysts frequently spring up, similar in all 
respects to those of the normal gland, but inferior both in size, and in the degree 
of development of their contents. These exogenous vesicles, according to him, 
constitute the only true hypertrophy of the gland. Another frequent alteration in 
the vessels is the obstruction and obliteration of the smaller arteries and capillaries, 
by the deposition of calcareous matter in their coats. 

b. The second primitive form primarily consists in the dilatation of the gland- 
vesicles, apparently from the retention of the secretion, which, through inactivity 
of the absorbents, is not taken back into the current of the circulation. The 
vesicles at first are simply enlarged: and are filled with complete cells distended 
with colloid matter, apparently of an albuminous nature. There are also to be 
seen more irregular masses of colloid matter, quite transparent, and containing 
numerous cells and nuclei, sometimes with crystals of cholesterine. As the 
disease advances, the cell-structure disappears, the walls of the vesicles and the 
intervening fibrous stroma become absorbed, so that their cavities coalesce, the 
vessels at the same time becoming obliterated, and thus is produced a third form 
of struma cystica. This change may continue until the whole gland becomes trans- 
formed into transparent colloid masses, in which few septa and no blood-vessels 
are to be seen. 

These two primitive forms of bronchocele are frequently combined, so as to 
produce all sorts of intermediate and complex varieties. Thus, the congestion 
and dilatation of the vessels may supervene on the glandulose form, and may 
occupy the intervening parts of the gland between the vesicles: and dilatation of 
the vesicles may supervene on changes more immediately connected with the 
vascular system. In either case the result is similar; and it is, therefore, impos- 
sible to find a sharp and definite boundary-line between the two primitive forms. — 
British and Foreign Medico- Chirurgical Review, Oct., 1848, from Zeitschrift fur Ra- 
tionale Medizin, 1847, Heft ii; and Edinb. Monthly Journal, Aug., 1848. 

18. On the Healthy and Diseased Structure of Articular Cartilage. By John Bir- 
kett, F.L.S.,F.R.C S. — From the constant influence of attrition upon the articular 
cartilage, it is evident that it would be rapidly destroyed if it were not endowed 
with a high capacity of nutrition and reproduction. The increase of cartilage, 
both in thickness and superficial extent, with the growth of the body, also fur- 
nishes evidence of the existence of this power which Mr. Birkett believes to 



1849.] 



Medical Pathology and Therapeutics. 



173 



reside in the nucleated cells enclosed in its blastema. The author assents to the 
observations of most physiologists, in believing cartilage to be a strictly non-vas- 
calar tissue, and he is at some pains to point out its analogies with the epithelial 
structures, such as epidermis or horn. He considers articular cartilage to hold 
precisely the same relation to bone as the epidermis to the corion ; the analogue 
of the latter being found in the very hard and peculiar layer of bone which lies 
immediately beneath the cartilage, between it and the cancelii. He observes, 
also, that the cancelii maybe regarded as representing the subcutaneous celiular 
layer, having, like it, areolar spaces, which are occupied by a fatty substance, 
the marrow. The arrangement of the capillary vessels in the articulating ends 
of bones, is in terminal loops, which pass into projections of the osseous tissue 
immediately in contact with the hard articular layer alluded to, and which the 
author regards as analogous to the papillae of the corion. 

The structure of this thin layer which intervenes between the vessels and the 
cartilage, differs from that of true bone : it is harder and denser: the lacunae are 
very regularly disposed, but the canaliculi which characterize the ordinary 
osseous tissue are absent. Its articular surface is irregular, and is closely fitted by 
corresponding irregularities of the cartilage. The other surface is equally closely 
adapted to the papillae of the osseous tissue, inclosing the looped capillaries, as 
before stated. 

The articular cartilage presents a variation in structure towards the free surface. 
The cells which, throughout two-thirds of its substance, have no definite arrange- 
ment, become flattened out, their long axis assuming the direction of the articular 
surface. This the author regards as a modification similar to that of epithelium, 
the flattening of the cells being the effect of the pressure to which they are 
subjected. It is this flattened layer of cells which has been regarded by writers 
as a prolongation of the capsular epithelium upon the cartilaginous surface. 

The destruction of cartilage in disease commonly proceeds by an infiltration of 
fatty granules, first into the cells, and ultimately into the hyaline intercellular 
substance. Thus disorganized and softened, the cartilage is removed by a 
gradual process of attrition, which the author considers as different from ulcera- 
tion. [We do not see any good grounds for this distinction. The attrition, 
ulceration, or molecular disintegration of articular cartilage has been carefully 
described and figured by Goodsir. (Anat. and Path. Observations, p. 17, and PL I. 
Fig. 13.)] 

Along with the process of destruction proceeds'the formation of a tissue, con- 
taining newly formed fibres and blood vessels, which arises whenever the 
cartilage is removed. These vessels are connected with, and spring from, those 
of the fibrous tissues adjoining the joint ; they are also frequently connected with 
those of the subjacent bone ; but, in order that this may be the case, it is neces- 
sary that the thin articular lamina of bone, as well as the cartilage, shall have 
been removed by attrition. It is only, therefore, when this layer has been 
entirely removed that complete synostosis, or vascular and organic union of the 
opposite ends of the bone, can take place through the medium of the newly- 
formed fibrous tissue and its vessels; and it is commonly observed that up to a 
late period in the process of anchylosis, portions of the articular layer remain, and 
prevent the bony union at the joints where they are present. — Month. Journ. Nov. 
from Guy's Hospital Reports, Oct. 1848. 

19. On the Pathological Changes in Mucous Inflammations. By Rud. Virchow. — 
All inflammations are to be considered as alterations of the nutritive process, by 
which the plasma of the blood is thrown out of the vessels in increased quantity. 
In inflammations of mucous membranes, their anatomical relations cause the exu- 
dation of this plasma upon a free surface. The plasma itself may be unchanged 
in constitution, or its fibrine may be increased in quantity. Differences in the 
constitution of the plasma determine differences in the result; and thus are estab- 
lished three leading forms of mucous inflammation: 

1. The Catarrhal Form. — In this the quantity of the blood-plasma is increased, 
and thrown out on the free surface. The cells (of epithelium) are formed in 
greater quantity than normal ; but they do not reach their normal development, 
being replaced constantly by an increased succession of new ones. The richer 
No. XXXIIL— Jan., 1849. 12 



174 



Progress of the Medical Sciences. 



[Jan. 



the plasma, the more rapid is ihe self-development. In the so-called chronic ca- 
tarrh, there are frequently found in the fluid cells quite perfectly developed, of the 
aspect of the ordinary epithelium. In acute ca-es the cells do not reach this stage 
of development ; they do not take on the epithelial forms characteristic of the 
part, but are thrown off as round, more or less spherical, mostly single-nucleated 
cells (mucous corpuscles). In the very acute, particularly the blennorrhauic forms 
of inflammation, almost all the cells are found in the earliest stages of develop- 
ment, smaller, more delicate, and containing often three lo five nuclei ; in short, 
possessing all the characters of the ordinary pus cell. All these forms may be 
considered as different grades of the epithelium cell; or, if the name epithelium be 
dropped, as cells developed on the surface of a mucous membrane, and whose 
only difference is their different degree of development. 

2. The Croupous Form — In this the plasma is not only increased, but is also 
altered in constitution, containing a large amount of fibrine, and coagulating more 
or less completely. The coagulum iies free on the surface of the membrane. 
This form is most frequent in the respiratory mucous membrane. The false mem- 
brane is either softened, friable (as in tracheal croup), and contains many cells; 
or it is of a more firm and fibrinous character (as in bronchial croup and exuda- 
tion into the air-vessels, or true pneumonia), and contains the products of rupture 
of the capillary vessels, red and colourless blood corpuscles. In pneumonia the 
stage of hepatization, where the air cells are filled with firm coagulated exudaiion, 
is generally succeeded by that of purulent infiltration, in which cells in every 
grade of development are formed in great abundance. In the first stages these 
cells have various degrees of resemblance to pus or epithelium ; in the stage of 
resolution of the pneumonia, we find the air-cells full of granular cells and masses, 
or a finely granular emulsion, which are to be considered as the retrograde steps 
of the newly formed cells. 

3. The Diphtheritic Form. — In this the exudation consists of nearly dry coagu- 
lated amorphous fibrine, and is infiltrated into the tissues composing the superficial 
layer of the mucous membrane, or rather of the submucous cellular tissue; for 
when it projects from the free surface, it is generally covered by the epithelial 
layer. Where organization proceeds in this kind of exudation, it is generally very 
imperfect; more commonly it is entirely absent, and a superficial slough is formed. 
Hence this form has been rightly considered as allied to a gangrenous form of in- 
flammation; it is, in truth, closely allied to hospital gangrene. — Archiv.fur Fatho- 
logische Anatomie, &c. Band. I. Heft 2. 

[We shall take another opportunity of adverting to these opinions, as well as to 
other views enunciated in this able journal. In the meantime, we may state that 
we agree in many of the author's conclusions, although differing from him in some 
points: as, for instance, in regard to the constitution of the blood plasma, which 
we believe to be least altered where the fibrine is in greatest quantity, as in the 
croupous and diphtheritic forms; and most altered where, as in the catarrhal forms, 
the inflammatory phenomena are but a slight alteration of the ordinary secreting 
process. We believe that the membrane, in its healthy state, possesses a power 
of selecting from the blood plasma a new product — mucus; that in disease the 
nature of this product is changed, and assimilated more and more to the plasma 
of the blood; in other words, that while the vessels acquire an increased power 
of pouring out the elements of the blood plasma, the power of the membrane to 
alter and select from these elements is diminished ] — Monthly Journal and Retro- 
spect of Medical Sciences, Oct. 1848. 

20. Pathological Anatomy of the Kidneys. — The Monthly Journal and Retrospect of 
the Med. Sciences, fyc, for the present year, contains an interesting series of papers 
by Dr. W.T. Gairdner, on the pathological anatomy of the kidneys. The follow- 
ing conclusions derived from his observations, he regards as especially important 
in relation to the pathology of renal diseases: — 

1. By far the greater part of the pathological lesions of the kidney arise from, 
or are connected with, the exudation of oleo-albuminous granules into the interior 
of the tubes and epithelial cells. 

2. The oleo-albuminous exudation is probably often preceded, and certainly 
occasionally accompanied, by vascular congestion; but when the quantity of exu- 



1849.] 



Medical Pathology and Therapeutics. 



175 



elation is considerable, more dr less complete depletion of the vascular system 
invariably occurs. This is a secondary result of the obstruction of the tubuli urin- 
iferi. 

3. The oleo-albuminous exudation occurs in two chief forms ; viz. first, Universal 
infiltration of the tubes throughout the organ; and second, Infiltration of particular 
sets of tubules, the rest remaining free, or nearly so. In the latter mode arise the 
granulations of Bright. 

4. There is' no essential anatomical difference between the exudations in the 
kidney which are the result of chronic processes, and those which have been 
considered as the result of inflammation. 

5. The capillary vessels of the kidney are subject to spontaneous obliteration 
(unaccompanied in the first instance by any visible lesion of the tubes), giving 
rise to the peculiar affection which I have called the waxy degeneration. This 
obliteration of the vessels is probably in all cases preceded by a stage of conges- 
tion. 

6. The consequence of the waxy degeneration is thickening and varicose dila- 
tation of the tubuli throughout the organ. 

7. The tubes of the kidney are subject to contraction and obliteration, in conse- 
quence of the desquamation of their epithelium; a condition resulting in atrophy, 
and complete disorganization of the organ. 

8. The desquamation of the epithelium occurs very frequently in all the other 
diseased conditions of the kidney. When sufficiently long-continued and exten- 
sive, it produces contraction, and this indifferently whether exudation be present 
or not. It is sometimes accompanied by vascular congestion in every stage of its 
progress. 

9. The earlier stages of the exudations can only be discovered by means of 
the microscope. The progress of the waxy degeneration, on the contrary, is best 
traced by the unaided eye. The desquamation of the epithelium is only to be 
discovered with certainty by means of the microscope, and is particularly apt to 
escape attention, under all circumstances, if the kidney only, and not the urine, be 
looked to. It results that careful investigation, both by the microscope and the 
naked eye, both of the kidney after death and the urine during life, are indispens- 
able to enable the pathologist to determine with exactitude the presence or absence 
of disease. 

21. Diseased Condition of the Tracheo-bronchial Mucous Membrane of the Artisans 
of Sheffield, and the Statistics of Mortality among them. — Dr. Craigie, in the late edi- 
tion of his elements of u General and Pathological Anatomy , ;? states: In the town 
and vicinity of Sheffield, two sorts of grinding of edged tools are practised; one, 
dry grinding on a dry stone, the other, wet grinding on a stone moistened with 
water. Many articles, as scissors, razors, and penknives, are ground partly on 
dry stone and partly on the wet stone. Others, as forks and needles, are ground 
mostly on a dry "stone. Table knives are ground principally on a wet stone. Saws, 
files, and scythes, are ground entirely on a wet stone. Dry grinding is most in- 
jurious, and tends most directly and effectually to induce bronchial and pulmonary 
disease, and thereby to abridge the duration of life amongst the grinders. The 
dry grinders, therefore, are most speedily destroyed. The life of the wet grinder 
is ofien prolonged to a considerable age. 

Of 1,000 scissors-grinders above 20 years of age, only 20 attain the age of be- 
tween 50 and 55 years; only 10 the age of between 51 and 65; and none live 
beyond the latter age; while of the inhabitants of Sheffield generally, 224 in 1,000 
are found living at 65 and above, and in the midland counties 413 in 1,000. Of 
artisans in this branch 843 in 1,000 die under 45 years of age. 

With the fork-grinders it is worse. Among 1,000 fork-grinders, aged above 20 
years, not 1 attains the age of 59; while in Sheffield, among 1,000 persons, 155 
are living at 59. Of these 1,000 persons, 472 die between 20 and 29 years, 410 
between 30 and 39; and the residual 115 are all gone before the age of 50. 

Among 1,000 razor-grinders above 20 years of age, 749 die under 41 years of 
age, the rest mostly between 41 and 60; between 61 and 65, only 5 are living; 
and after 65 all are gone. 



176 



Progress of the Medical Sciences. 



[Jan. 



Of the penknife-grinders, not 1 in 1,000 arrives at the age of 60; 731 die be- 
fore the 40th year; and the rest are all destroyed before the 60th year. 

Saw-grinders, file-grinders, and scythe-grinders, who work on the wet stone, 
are less liable to bronchial disease, and are longer lived. The numbers pursuing 
saw-grinding are not great. Yet among seventy-eight persons engaged in it in 
1843, nine were between sixty and sixty-live, and one died between sixty-six and 
seventy, and one at seventy-nine. 

The number of scythe-grinders is also not great. In 1843, there were thirty; 
of these, eight were between forty-one and sixty years of age. Both the saw- 
grinders and the scythe-grinders are exposed to accidents, sometimes fatal, from 
the breaking of the stone. 

The lesions which produce this great mortality are of a complicated character. 
The most common lesions are chronic inflammation, with thickening of the bron- 
chial membrane, enlargement or dilatation of the bronchial tubes, emphysema, 
and expansion of the pulmonary tissue. 

The bronchial glands are enlarged, or converted into a black, hard, gritty sub- 
stance, varying in size from half a marble to a large hazelnut. In dividing these 
glands, the sound emitted is the same as if the scalpel were dividing a soft stone, 
and the section is black and polished, and grates over the edge of the knife. Such 
masses are commonly detected in grinders who have belonged to the most de- 
structive branches. Similar soft, sectile, gritty, or stony matter is found in almost 
every part of the lungs, in portions varying from the size of a currant to that of a 
bean; adhesions between the pulmonary and costal pleura are also frequent. In 
some instances the lungs present an appearance as if black currants had been 
distributed through their whole substance, and accompanied with similar bodies, 
larger in size, but hard and gritty like them. These currant-like bodies are also 
observed on the surface of the lungs. They are supposed to consist of the dilated 
extremities of veins containing some of the solid constituents of the blood. 

Tubercles are also occasionally found, with their consequences, vomicae. 

Another state, frequently observed, is engorgement or infiltration of the lungs 
with a dark coloured fluid, which is ascribed to the inhalation of the fine black 
dust floating in the atmosphere during the operation of glazing. 

On the mode of production of these lesions, or the order of their succession, 
observers are not agreed. 

22. Fungus Hcematodes of the Brain. — Mr. Prakkerd relates (Prov. Med. and 
Surg. Journ., Sept. 20th, 1848) a case of fungus hsematodes of the brain which 
is remarkable for the little disturbance in the functions of the brain which it oc- 
casioned. 

The subject of it was a woman forty-four years of age. married, menstruated 
regularly, and mother of several children, for the last ten years of her life suffered 
from intense pain in the head, occurring at intervals, and for nearly the whole of 
this time (nine out of the ten years), was completely blind. For the last few 
years, her health was evidently affected by the continued suffering she endured. 
Latterly, counter-irritation, such as setons, issues, and the long issue through the 
scalp, were principally relied on, but afforded only temporary relief, and she was 
gradually worn down by the suffering, and ultimately sank, exhausted. Throughout 
the whole period her mental powers were unimpaired: she was very conversible 
and intelligent, and her symptoms were not such as would indicate that much 
structural disease of the brain existed. 

Autopsy, eight hours after death. — The head only was examined. The right 
hemisphere of the brain was healthy: the left rather softened, and the anterior 
and inferior portion was occupied by a firm tumour, weighing upwards of eight 
ounces, of an oval shape, and occupying more space than a cricket ball. In ap- 
pearance it was of a dark purple colour, and in structure lobulated. The optic 
nerve was found extremely small, having suffered gradual compression during 
the increase of the tumour. 

The tumour was examined by Mr. Bowman of King's College, who pronounced 
it to be a decidedly fungoid growth- In some portions the blood-vessels had 
given way, constituting fungus hsematodes, and other parts presented the character 
of medullary sarcoma. A section examined under the microscope presented a 



1849.] 



Medical Pathology and Therapeutics. 



177 



number of healthy nucleated cells, interspersed with some that were diseased ; 
the latter were larger than the former, and contained within them smaller cells. 
In the substance of the tumour numerous fibrous bands might be discerned with 
the naked eye. The tumour was highly organized, and very vascular. Mr. 
Bowman thought the case extremely interesting from the unusual size of the 
tumour, the slowness of its growth, (ten years.) and the absence of any disturb- 
ance in the functions of the brain. 

23. On Photuria, or Luminous Urine. — Cases, however rare, have been cited, 
in which the urine, as it passed from the urethra, had aluminous appearance. The 
phenomenon has not been explained, wherefore the following case, with the ob- 
servations of M. Fallot, will be read with interest: — 

A man, aged sixty, had for many years, at intervals, passed luminous urine ; the 
luminous appearance was most distinct as the fluid dashed on the ground, but a 
few sparks were seen in the stream as it passed from the urethra. Examination 
discovered nothing particular in the fluid, which varied in its constituents accord- 
ing to circumstances. 

M. Fallot thinks that these cases would be found to be more common if atten- 
tion were directed to them, but that as the affection is not accompanied by any 
notable derangement of health, it passes unobserved. In the case referred to, the 
patient had never alluded to the circumstance until he was questioned concerning 
it, in consequence of its being accidentally witnessed by M. Fallot. — Prov. Med. 
and Surg. Journ. } Oct. 1848, from Rev. Med. Chirurg., July, 1848. 

24. The Vibration of the Thoracic Walk, — a Diagnostic Sign of Disease. — By the 
term thoracic vibration, M. Monneret designates the oscillation of the parietes 
of the chest, perceptible by the application of the hand upon the thorax of a 
person who sings or speaks aloud. The vibrations are more distinct in the 
right side than in the left,— and in the interior than in the posterior regions. The 
vibration is propagated from the larynx, by the walls of the air tubes, by the solid 
elements of the thoracic parietes, and by the air contained in the lungs. The 
larynx is the sonorous instrument, and the phenomena perceptible by the applica- 
tion of the hand, are caused by the propagation of the undulations of sound, through, 
the agency of good conductors. By disease of the chest, the physical conditions 
of these conductors being modified, the pectoral vibrations undergo changes, which 
Dr. Monneret has studied for the purpose of discriminating from each other the 
various alterations of the respiratory organs. 

The vibration is increased in pneumonia, and first stage of consumption; it is 
diminished in pleurisy, emphysema, and pulmonary excavations. 

In pneumonia thoracic vibration is invariably increased ; and to that degree, 
that even when the signs furnished by auscultation and percussion are still of a 
doubtful nature, a positive diagnosis may be obtained, — a circumstance peculiarly 
advantageous in the diseases of infancy, when auscultation is difficult, and its re- 
sults questionable. The phenomena of vibration are also increased in pulmonary 
cedema, — a fact testified in the last stages of disorders of the heart. In the first 
period of consumption when the lung is condensed by the presence of crude tuber- 
cular masses, it often happens, that auscultation furnishes only negative signs, or 
increased roughness of the respiratory murmur, so slight as to leave some hesita- 
tion in the mind of the observer. In such cases, says Dr. Monneret, the diagnosis 
is powerfully assisted by the application of the hand, whilst the patient speaks 
aloud — the vibration being invariably increased in the diseased regions. Again, 
in pleurisy, attended with the formation of plastic adhesions and false membranes, 
no fluid being exuded between the lung and the thoracic walls, the vibration 
caused by the voice is considerably augmented. 

It is, on the contrary, diminished or abolished in pleurisy, when liquid effusion 
has taken place. The increase or diminution of the morbid secretion are also 
marked by corresponding modifications in the transmission of sound to the hand. 
In pulmonary excavations of some extent, the vibration of voice is decreased or 
altogether abolished; but, on the margin of the cavities, it is on the contrary in- 
creased by the condensation of the lung around the ulceration. In pneumothorax, 
Dr. Monneret had four times occasion to study the vibrations of the wads of the 



178 



Progress of the Medical Sciences. 



[Jan 



chest, and in all the cases he found them abolished in the regions corresponding 
to those occupied by the effusion of air. In pulmonary emphysema, also, the 
undulations of sound perceptible to the hand are diminished, — a fact easily ac- 
counted for by the rarefaction of the tissue of the lungs. 

Thus, the study of the vibration of the thoracic walls can be made available 
in the diagnosis of doubtful cases, and forms a valuable addition to the other phy- 
sical signs of thoracic disease. — Med. Times, from Revue Med.-Chirurgicale, Sept. 
and Oct. 1848. 

25. On Influenza and Cholera. — Dr. Marc D'Espine, after describing the 
epidemic of influenza which prevailed at Geneva during the present year, insti- 
tutes a parallel between the progress of that disease and the cholera. 

1. Influenza is a u peregrinating' 7 disease, which has never appeared sponta- 
neously in Geneva, as shown by the history of seven epidemics in 60 years. 2. 
If seasons and meteorological conditions are not without their influence on the 
physiognomy of the disease, its general diffusion, and the nature of its complica- 
tions, they seem to be powerless as regards the epochs of its appearance and 
duration. 3. It is propagated successively from one country to another, but with 
varying rapidity in different directions. Thus, latterly, it has more rapidly ex- 
tended itself from Paris to Marseilles, than from Paris to Geneva. 4. Thus far 
influenza and cholera agree; but a first difference between them is, that while 
cholera seems to radiate from towns to the adjacent country, as if, to develop its 
influence, it required agglomerations of people, influenza seems to act during 
its route just as easily upon the scattered inhabitants of rural districts as upon those 
of crowded towns. 5. Both diseases, contrary to most epidemic affections, may 
attack the same individuals several times. 6. While cholera attacks rather more 
males than females, influenza attacks a decidedly larger proportion of the 
latter. 7. Children are generally spared by both diseases. While cholera com- 
mits great havoc among the aged, influenza especially attacks those between the 
ages of 20 and 40; but this diff erence becomes effaced when, instead of the number 
attacked, w 7 e count the mortality; for as influenza is seldom fatal before 50 or 60, 
like cholera, it carries off a large proportion of the aged. 8. The influenza, like 
the cholera, is a general disease, affecting the entire organism, and its physiog- 
nomy is characteristic enough to enable us to distinguish it from other acute diseases. 
Yet it approaches nearest to catarrhal affections, just as cholera does to acute 
diseases of the digestive organs. 9. Influenza is scarcely ever mortal in its 
simple state, becoming so from complication with thoracic inflammations. 10. 
An epidemic of influenza is not accompanied with any diminution in the number 
or mortality of the ordinary diseases of the season and place. During the pre- 
valence of cholera at Paris in 1832, the number of deaths unconnected with it 
was just the same as if it had not been present. 11. Although influenza and 
cholera are diseases of very different severity, their mortuary effect does not vary 
so much as might be supposed. The epidemics of influenza in 1837 and 1848 
nearly doubled the mortality of the populations on which they fell, which is much 
about what the cholera did in Paris in 1832. It is true the cholera lasted, not 
two months like the influenza, but six; and though causing one death in every 
two, attacked only one in twenty, while the influenza attacks one-half of the 
population. 12. While the influenza may appear several times without neces- 
sarily being followed by the cholera, this last would seem to be generally pre- 
ceded by it. — Brit, and For. Med.-Chir. Rev., Oct. 1848, from Gaz. Med. de Paris, 
Nos. 20 and 21. 1848. 

26. On Delirium in Pneumonia. By M. Grisolle. — This phenomena is of im- 
portance, not only because it may arise from different causes, offering opposite 
indications, but also because it may, in some cases, give rise to the belief in the 
existence of a cerebral disease, when in fact the affection is seated in the lungs. 
And the necessity of a complete examination of the organs is shown by the fact, 
that where this has been neglected, it has not uncommonly happened that persons 
have been carried to lunatic establishments on account of a temporary mania, de- 
veloped during the acute stage or the resolution of pneumonia. 

A third part of such cases manifest themselves in persons addicted to drinking : 



1849.] 



Medical Pathology and Therapeutics. 



179 



and it has been said that pneumonia of the apex, especially, gives rise to this 
symptom; but. of 27 patients exhibiting delirium, M. Grisolle has found the apex 
affected in 9, the base in 14, and the middle lobe in 4; and MM. Andral and 
Briquet have made similar observations. It may, however, be stated, that double 
pneumonia is more likely to give rise to delirium than single. It manifests itself 
more frequently in men than women, in the proportion of 21 to 6, and of these 
27 patients, 3 only were less than 40 years of age — the usual age being between 
50 and 60. MM. Hourmann and Dechambre state that among the old women at 
Salpetriere, delirium is an habitual accompaniment of pneumonia. The symptom 
generally occurs from the 4th to the 6th day, especially in drunkards, although 
it is by no means rare to find it at the commencement of the pneumonia, or even 
preceding it by from one to four days. Lastly, when the progress of the pneumo- 
nia has been rapid, it may not exhibit itself until the decline of the disease, or 
during convalescence. 

It may assume various forms, from slight incoherence to furious delirium; and 
in drunkards there are the hallucinations, excitement, sleeplessness, and tremor, 
observed in delirium tremens. This last form, if not relieved, terminates in coma and 
death in four or five days. The autopsy generally exhibits only some vascularity 
of the pia matter and injection of the cerebral substance, signs of recent menin- 
gitis being observable in about a fifth of the cases. The presence of this delirium 
gives rise to an unfavourable progno>is, not only on its own account, but because 
of its generally being conjoined with extensive pneumonia; but the prognosis 
is less serious in the case of drunkards than in others. Of 27 cases, M. Grisolle 
lost 8. 

Although in the treatment of the case which has given rise to these remarks, 
bleeding was not resorted to, in consequence of the age of the patient, the long 
duration of the disease, and the smallness of the pulse. — antimony and a blister 
being successfully substituted, — yet it is, in general, far from being contraindicated. 
When the delirium seems to predominate over all the other symptoms, M. Reca- 
mier has given musk, in the form of pills, in doses of from eight to ten decigrammes, 
with success : but M. Grisolle has frequently failed with it. In the cases of drunk- 
ards, full doses of opium, continued until sleep is procured, are indicated; with 
which full doses of tartar emetic may be advantageously combined. Alcoholic 
drinks are also highly useful, not only for the cure of the disease, but also, as M. 
Chomel long since observed, for its prevention. We should, therefore, inquire 
into the patient's habits, and remembering that in drunkards delirium comes on 
from the fifth to the seventh day, we should, if any trembling of the lower lip and 
sleeplessness indicate the approach of the complication, at once administer the 
alcohol, and often the best effects will follow. — Brit, and For. Med.-Chirurg. Rev., 
from L } Union 31edicale, 1848, No. 9. 

27. Inflammation and Ulceration of the (Esophagus. — A man, aged sixty-five, was 
ill with an acute ascites, dependent upon some abdominal disease, which a post- 
mortem examination proved to consist of a deposition of numerous malignant tuber- 
cles, which studded the greater portion of the sub-peritoneal areolar tissue, the 
liver, and some other parts. Five days before his death, he first complained of 
pain in the throat on every attempt at deglutition. The next morning incessant 
sickness began, the stomach rejecting whatever was introduced into it, together 
with large quantities of a dark bistre-coloured matter, which was evidently blood, 
acted on by the gastric fluid. Though he al ways succeeded on making the attempt 
to swallow, the effort was of a spasmodic character, and accompanied with con- 
siderable pain in the throat and along the sternum. This was generally of an 
aching character; but the juice of an orange, he told me, caused a smarting, cut- 
ting sensation. 1 examined the throat with the aid of a speculum lamp, and, as 
far as I could see, the mouth, the palate, the tonsils, and the pharynx, were all in 
a healthy condition. On the fourth day, there was less of the black substance, but 
he vomited several clots of muco-purulent matter, which exactly resembled the 
sputa of bronchitis in its latter stage. My patient had been gradually becoming- 
weaker from the commencement of this attack, and he died from asthenia on the 
fifth day. Attempts had been made to support him by means of nutritious ene- 
rnata; but the fluids could be injected only in very small quantity, and relumed 



180 



Progress of the Medical Sciences. 



[Jan. 



the instant the pipe was removed, circumstances which were sufficiently explained 
by the very contracted state of the rectum and colon which was found after death. 
Since the commencement of the oesophageal symptoms, those referred to the ab- 
domen had remained in abeyance, and the ascites was greatly on the decrease. 

The post-mortem examination presented several lesions, but those connected 
w ? ith the oesophagus alone seemed immediately concerned in the fatal result. The 
whole mucous membrane of this part was in an ulcerated condition, the ulcers 
appearing of very recent formation, having irresular edges, running into one 
another, without any appearance whatever of granulation. In some pans the 
whole thickness of the mucous membrane was destroyed : in others the ulceration 
was quite superficial. The veins were much congested, and the vessels had given 
way at intervals, for several points of extravasafed blood were found in the sub- 
mucous areolar tissue. 1 discovered three or four minute tubercles in the substance 
of the mucous membrane, but was unable to determine whether they were of a 
malignant character. These lesions were confined to the oesophagus, for the mucous 
membrane of the stomach was perfectly healthy, and the pharynx presented no 
trace of disease. 

A brother practitioner requested me to see. with him, a gentleman who had 
been ill for several days, with symptoms of a common catarrh, caught, as it was 
supposed, by his getting wet on a fishing excursion, and remaining for some hours 
in his damp clothes. He was now becoming much debilitated; and there were 
symptoms threatening the approach of a typhoid state; whilst the urgency of the 
case was greatly increased by a difficulty of swallowing, which had recently super- 
vened. I found the patient really more ill than I had expected. The whole mu- 
cous membrane of the mouth and pharynx, as far as could be seen, was in a state 
of superficial ulceration, being of a yellowish gray colour, bleeding readily, and 
secreting a sanio-purulent matter. This diseased condition terminated in front, 
exactly at the point where the two lips come in contact on the mouth being closed, 
so that the outer portion of each lip was unaffected. The conjunctiva of the lids 
and globe was in the same state, secreting a muco-purulent matter, which gummed 
the lids together during sleep: whilst a similar condition of the Schneiderian mem- 
brane was indicated, by the nasal passages being blocked up by sanio-purulent in- 
crustations. The patient was now sitting in his arm-chair ; his manner was hurried 
and tremulous; and his wife assured us that there had been a good deal of mut- 
tering delirium during the night. The puise was feeble, and the skin cold and 
clammy. What was at first a mere difficulty of swallowing, now amounted to a 
complete inability. Wishing to witness the effort, I requested the patient to try 
some brandy and water; he took a small quantity of it into his mouth, and made 
a convulsive attempt to gulp it down ; but. instead of entering the esophagus, the 
whole of it returned by the nostrils. From the symptoms, I could have but little 
doubt that the mucous membrane of the oesophagus, at least in a great part of its 
extent, was in a similar condition to that of the mouth and the other parts which 
have been mentioned. 1 felt confident, however, that the difficulty in swallowing 
arose rather from a spasmodic affection of the muscles, than from any mechanical 
impediment. On this view of the case, we determined upon using active counter- 
irritation along the neck. On either side, behind the trachea and larynx, and from 
the angles of the lower jaw to the clavicles, we freely applied the glacial acetic 
acid, by means of a camel's-hair paint-brush; this produced for a few seconds its 
usual intolerable smarting, but the relief to the dysphagia came sooner than we 
could have anticipated, for the patient was able to swallow immediately after the 
operation. From this lime he had no impediment to deglutition, though the effort 
was still accompanied with pain. We now prescribed the sulphate of quinine, 
and allowed our patient as generous a diet as he could be induced to take, with a 
fair proportion of alcoholic stimuli. The vital powers, which had been fast sink- 
ing for want of nutrition, now revived, and we soon ceased to be alarmed about 
the result. The mouth was directed to be frequently washed with a lotion, com- 
posed of the linimentum sernginis, lime-water, and laudanum, until returning 
action, indicated by this application producing pain, warned us to its discontinu- 
ance. In about ten days all local symptoms had disappeared, though our patient 
still remained weak from the effects of his illness. 



1849.] Medical Pathology and Therapeutics. 



181 



In his book 11 On Diseases of the Stomach/"' the late Dr. Abercrombie relates the 
following instance of this, as he calls it, rare affection. u A gentleman, aged 
twenty-six, came to town in June, 1826, to consult me about complaints in his 
head. On his journey he thought he had caught cold in crossing the Frith of Forth, 
and when I saw him he complained of his throat ; and there was a glandular swell- 
ing on the right side of the neck. His voice was hoarse, with a peculiar husky 
sound. The fauces were of a bright red colour, without much swelling, but were 
covered in several places with aphthous crusts. He was at this time riot confined, 
and there was not much fever; but, after a few days, he became more feverish, 
the other symptoms continuing as before. He was now confined to bed. and 
actively treated, and after eight or nine days he was much better, so as to be able 
to be out of bed; but there was still some soreness of the throat, with small aph- 
thous crusts, and a husky sound of the voice. After a few days there was a recur- 
rence of the fever, which now assumed a typhoid type, with considerable appear- 
ance of exhaustion. He had some dyspnoea, with much difficulty of swallowing. 
The attempts to swallow excited sometimes cough, and sometimes vomiting, and 
by both were brought up considerable quantities of a soft membranous substance. 
He became more and more exhausted, without any remarkable change in the 
symptoms, and died at about the end of three weeks from the first appearance of 
the disease. 

Inspection. — The whole of the pharynx was covered with a loose, soft, adven- 
titious membrane, which also extended over the epiglottis; and portions of it were 
found lying in small irregular masses, within ihe larynx, at the upper part. A 
similar membrane was traced through the whole extent of the inner surface of the 
oesophagus, quite to the cardia. Near the cardia it lay slightly attached, forming a 
soft continuous mass, about the third of an inch in diameter, and with the oesopha- 
gus closely contracted around it. The other parts were healthy.' — Prov. Med. and 
Surg. Journ.j Oct. 4, 1841. 

28. Peculiar Obstruction of the Bowels. By Daniel Donovan. M. D. (Dublin Med. 
Press, Nov. 8, 1848.) — The author states that he has met within a week with four 
cases of obstructed bowels, occasioned by a large mass filling up the rectum, and 
incapable of being passed per anura. The symptoms in all the cases being 
exactly alike, the history of one will suffice to explain the others. 

Patrick Hanly, aged 50, applied at the Skibbereen Dispensary on the 23d inst. 
He was then labouring under severe tenesmus and bearing-down pain ; and to use 
his own words, "had a bowel complaint on him for four days, and could pass 
nothing but red blood.'' He further stated that u he could make no water, and that 
there was a lump in his seat." 

This description of his disease, and the fact that my attention had been directed 
to the subject by my friend Dr. Fitzgibbon, who detailed the particulars of two 
similar cases that occurred in his practice a few days before, led me to make an 
examination, and I discovered at the orifice of the gut a large solid mass. The parts 
around the anus were puffed out, and the sphincter was distended to the utmost. 

It was evident that mechanical means could alone relieve the sufferer: and on 
using the handle of a pewter spoon for the purpose, a large quantity of conso- 
lidated potato skins, with some portion of the substance of the tubers and coarse 
Indial meal, was dislodged. The retention of urine was immediately removed, 
and the other symptoms relieved, but recurred, and required for four' successive 
days the same treatment, together with the administration of large enemata of 
warm water, which assisted in bringing down and breaking up the firm mass that 
filled the intestine. 

These concretions are almost entirely formed of potato skins, and are conse- 
quent on the use of diseased tubers, in which the peel and farinaceous substance 
of the potato are so intimately blended together, that it is impossible to detach the 
former in the ordinary way ; and large quantities of the skins are consequently 
swallowed, and accumulating in the bowels, form the obstructing masses that "I 
have described. 

It is of much importance that a correct diagnosis should be formed in this dis- 
ease, as from the similarity of some of the symptoms, it may be confounded with 
dysentery, and lead to very unavailing or even mischievous treatment. 



182 



Progress of the Medical Sciences. 



[Jan. 



"The straining at stool, the evacuation of blood from the ulcerated lining of the 
rectum, and the retention of urine that may be mistaken for suppression, are all 
symptoms which are exhibited by the malignant dysentery that has raged for the last 
two years, and may lead to an incorrect diagnosis of the disease that I am alluding 
to ; but there is one diagnostic character that, once observed, cannot be mistaken, 
and which clearly points out the nature of this complaint — I allude to a very pe- 
culiar sour smell from the body of the patient, like that exhaled from fermenting 
potato skins, — a substance used by weavers in the manufacture of coarse linens. 
Whenever this smell is recognized in cases exhibiting the other symptoms that I 
have described, an immediate examination of the rectum should be made, and 
mechanical means should be immediately employed to unload the gut, as any 
other plan of treatment would be perfectly useless. 

" A similar species of obstruction was very commou in the autumn of 1846 
from the use of boiled wheat." 

29. On the Simultaneous Progress of Gout and Phthisis. — Dr. Garrod read a paper 
to the Westminster Medical Society (Nov. 18, 1848) on the simultaneous progress 
of cases of gout and phthisis. He was induced to bring this subject before the 
notice of the Society, as in a paper on phthisis, communicated during the last 
session, it was asserted that a gouty condition of the system or blood was inimical 
to the development of tubercular disease, and it was suggested that, for the pur- 
pose of preventing or curing the latter affection, an attempt should be made to 
produce a gouty diathesis; and even the internal administration of urate of soda 
was hinted at. Dr. Garrod first spoke of some recent researches he had made on 
the subject of gout, which will appear in the volume of the Transactions of the 
Royal Medico-Chirurgical Society now in the course of publication, and described 
what he considered to constitute a gouty condition of blood, alluding to the pre- 
sence of an excess of uric acid, before and during the paroxysm, in acute gout, 
and as an almost constant accompaniment in those forms of the disease where 
tophaceous or chalk like deposits take place in different parts of the body. Dr. 
Garrod then stated, that if the gouty and tubercular diathesis w T ere antagonistic, 
phthisis would never become developed in the inveterate forms of gout above 
alluded to. To prove, however, the fallacy of the idea, the following case was 
related: — A young man, aged twenty-eight, a native of London, whose father and 
grandmother had suffered from gout, applied for relief at University College Hos- 
pital, and was admitted, under the care of Dr. Williams. He was a painter by 
trade, and for some years he had been of very intemperate habits, but until the 
last few, had had plenty of food and clothing. From the age of seventeen, he 
had suffered from what he termed " rheumatism," (gout?) but had had an affec- 
tion of the heart with it. Formerly, he was of full habit, but about three years 
since, began to lose both flesh and colour, although he did not feel particularly ill, 
and had no cough at the time. He was soon after seized with an attack of gout, 
both in his feet and hands, tophaceous deposits formed, and he was confined to 
his bed for twenty-eight weeks. About two months after his recovery, he was 
again attacked, and then had a severe cough, with expectoration of a greenish 
hue. The pectoral symptoms continued for about four months, the gouty two 
months longer. From this date until his admission into the hospital he was con- 
stantly suffering from chest affection and gout; haemoptysis had occurred once, 
and deposits of urate of soda frequently came away from his joints. When ad- 
mitted into the hospital he was pallid arid emaciated: complained of pain in various 
joints arising from gouty inflammation ; also of pain in his side, cough, and expec- 
toration of a muco-purulent character. On physical examination, clear evidence 
was found of the existence of tubercular deposition in both lungs, especially the 
left, at the apex of which, a distinct cavity was indicated by the production of 
pectoriloquy and cavernous respiration ; during the remaining month of his life, 
the gouty affection continued to progress, now appearing in one part, now in an- 
other, and occasionally with the discharge of urate of soda from some of the joints. 
The thoracic affection also continued to advance, accompanied with hectic symp- 
toms, increase of cough, and sharp pain in different parts of the chest, until he fell 
into a state of stupor, and so continued for a day or so, when death took place. 
The post-mortem appearances fully proved the accuracy of the diagnosis. At the 



1849.] 



Medical Pathology and Therapeutics. 



183 



apex of the right lung a cavity was found, large enough to contain a walnut, the 
rest of the lung being studded with scattered tubercles in different stages of de- 
velopment. The apex of the left lung was excavated to the depth of four or five 
inches, and the remaining portion was sprinkled throughout with gray tubercles. 
The heart was healthy ; the liver had patches of soft tuberculous deposit on its 
surface; the kidneys were small, and many of the tubuli filled with a white mat- 
ter, consisting of crystallized urate of soda and uric acid: spleen enlarged. Mu- 
cous membrane of the colon ulcerated in patches. An examination of the blood 
was also made, and it was found to contain a very large amount of uric acid, larger 
than Dr. Garrod had ever before obtained. Some remarks were then made on 
other cases, in which gout and phthisis existed together ; the rarity of the combi- 
nation being easily accounted for by the fact, that gout in general does not appear 
till after the age of forty, whereas tubercular disease is much more Irequent beiore 
that period. It also appeared very doubtful to the author whether, granting the 
correctness of the hypothesis advanced in the paper alluded to, a gouty condition of 
blood could be induced by the internal administration of urate of isoda. — Lancet } 
Dec. 2, 1848. 

30. Influence of Physical Agents on Variola. — M. Serres. in a memoir read to the 
French Institute, (25th September.) inquires, why the skin is the seat ol election 
of the variolous pustule, while the mucous membranes are comparatively seldom 
affected ? This he considers to be owing to the influence of the air on the de- 
velopment of the pustules, which are most largely developed on the face and 
hands, where there is the greatest exposure ; and most scanty on the hairy scalp, 
the axilla, and about the genitals, where the parts are protected from the contact 
of the atmosphere either by the presence of hairs or by posiiion. The influence 
of the air upon the production of ihe variolous pustules is further shown, by the 
circumstance, that when the mucous membranes are attacked, it is invariably 
those which are exposed to the contact of the air. Thus, in fifiy cases in which 
the pharynx, epiglottis, and larynx were attacked by the pustules, he has uni- 
formly found that these stopped short at the glottis, the oesophagus remaining 
quite sound. In the majority of instances, likewise, the conjunctiva, vagina, and 
rectum, are exempt from the affection, being in the normal state secluded from 
the contact of the atmosphere ; but if these membranes are everted as in trichi- 
asis, and in prolapsus of the uterus, and rectum, they are readily attacked by the 
pustules. 

M. Serres considers, that these views as to the development of the pustules 
of variola, are borne out by experiments. Thus he finds, that, by covering the 
pustules with little cups of darkened glass, or enveloping them in honey, or in a 
layer of fatty matter, their progress is arrested ; a result which he ascribes solely 
to the exclusion of the air. 

The condition of the atmosphere (as might be expected from the above 
remarks) exercises a most important influence over the severity of small-pox. 
From an extended consideration of the epidemics of different countries, it is 
found that the disease reaches its maximum of intensity in a dry atmosphere; 
and that thedry heat of the south and dry cold of the north are equally unfavour- 
able in relation to variola. This is particularly shown in the epidemics of 
Holland; and it was this circumstance which Sydenham had in view, when he 
said that a moderate temperature was especially favourable in variola. 

In the Hospital of La Pitie." during the years 1817, 1818, and 1819, the vario- 
lous patients were treated in ill-ventilated, dark, and moist wards; there were 
few confluent cases. However, conceiving that these wards were insalubrious, 
M. Serres had the patients removed to wards in the fourth story, very dry-, 
exposed to the south and north, warm in summer and very cold in winter. The 
result was unfavourable : the eruptions became more grave, and the mortality 
increased. Under these circumstances, the patients were again removed to the 
ground floor. Thus was illustrated, on the small scale, the same truth as springs 
from a consideration of the extended epidemics before mentioned. 

If it be thus proved that moisture exerts an influence on the development and 
intensity of variola, it is not unlikely, according to M. Serres, that the same 
cause tends to impede the development and efficacy of the vaccine pustule. It 



184 



Progress of the Medical Sciences. 



[Jan. 



remains to be decided by statistics whether the vaccine virus is less active and 
less preservative in its influence in the moist climates of the south of Europe, than 
in the diier ones of the north. — Month. Journ., Nov.. from L 'Union Medicale, Oct. 
5th, 1848. 

31. On the Employment of Nitrate of Potass in Acute Rheumatism : with Suggestions 
for the Use of Siline Solutions as External Applications in Local Rheumatic Inflammation. 
By W. R. Basham, M. D. (Proceedings of Royal Med. and Chirurg. Soc, Nov. 
14.) — The author takes, as the basis of his essay, the following facts: 1st, that in 
acute rheumatism, as in other inflammatory diseases, the most important changes 
in the composition of the blood are the increased quantity of fibrine, and the de- 
ficiency of the saline ingredients; 2d, that where this slate of the blood exists 
there is a special disposition to the deposit of fibrine, and the formation of adven- 
titious tissues; while in diseases in which the fibrine is deficient, and the salts in 
excess in the blood, the blood does not coagulate, and hemorrhages of a passive 
character occur: and 3d, that although, as his own experiments have satisfied him, 
saline solutions have not the power of dissolving coagulated fibrine, yet certain 
salts in solution, mixed with the blood at the moment of its escape from the body, 
possess the property of suspending or retarding the separation of the fibrine. He 
next inquires whether any therapeutic principle can be derived from these facts, 
and proposes the question, whether saline remedies, largely employed, may not 
suppress the tendency to the fibrinous exudation, or retard it, so as to give time 
for other remedies to diminish the proportion of fibrine present in the blood. With 
reference to this question, he alludes to the observations of several physicians on 
the use of nitrate of potash in acute rheumatism, and details his own experience 
of its effects. He gives one, two. or three ounces of nitrate of potass, largely 
diluted, (in two quarts of water,) in the twenty-four hours. In the majority ol 
cases no obvious effect is produced on the force or frequency of the pulse, the 
digestive functions, or the quantity of urine exuded. But the urine always acquires 
a high specific gravity, and nitrate of potass may be detected in it. The swelling, 
heat, and pain of the joints affected with rheumatism are relieved in a most marked 
degree, even when no other remedies are employed at the same time. There is 
a certain amount of exemption from cardiac complication ; and cardiac inflamma- 
tion, when present, is more amenable to remedies. In a case which the author 
relates, he examined the blood of the patient before the commencement of the 
saline treatment, and again after this treatment had been continued for some days. 
In the first instance it was buffed and cupped, the fibrine was in excess, and the 
salts were deficient. After the administration of the nitre there was no buffy coat, 
the proportion of fibrine had diminished, and that of the salts greatly increased. 
The author presumes, therefore, that while the internal use of the nitrate of potass 
assisted to restore the proportion of the saline constituents, the other treatment 
employed tended to lessen the excess of fibrine. Some remarks of Mr. Gulliver 
have led the author to investigate the effects of the external application of saline 
matters to parts affected with rheumatism. His experiments have been principally 
made with nitrate of potass. In chronic rheumatism he has used the iodide of 
potassium, and in gout the bibasic phosphate of soda. He applies the saline sub- 
stance by means of the spongio-piline, a portion of which, large enough to envelop 
the part affected, having been moistened with water, the salt employed is sprinkled 
in powder freely on the spongy surface: it is then applied to the part, and secured 
with a roller. In numberless instances, by this simple treatment, he has witnessed 
the most palpable and instant relief to the local inflammation. Constitutional 
remedies were employed at the same time, but the relief was proved to be due 
to the saline applications, by the fact, that where several joints were affected, only 
those were relieved to which the salt was applied. At the end of the paper the 
author gives an abstract of seventy-nine cases of acute rheumatism, showing the 
results of treatment, and other particulars. 

Dr. Henry Bennet had witnessed the results of a similar mode of treatment to 
that practised by Dr. Basham, in Paris, in 1837, and subsequently. In that year, 
M. Gendrin had instituted a series of experiments with the nitrate of potash, in 
acute rheumatism. He gave it in doses varying from six to twelve drachms. He 
had seen this treatment adopted in about as many cases as were recorded in the 



1849.] 



Medical Pathology and Therapeutics. 



185 



paper before them, and with the same result. It was found to be a safe, powerful, 
and energetic remedy. In the experiments of M. Gendrin, no other medicine 
was given, not even aperients. The result of the treatment was generally suc- 
cessful, but in every tenth or twelfth case it was found necessary to resort to the 
old remedies, bleeding, calomel, and opium, &c. It was noticed, also, ihat patients 
treated with the nitrate of potash were unusually free fiom cardiac disease, more 
so 7 indeed, than when any other kind of treatment was adopted. Another notice- 
able circumstance connected with this mode of treatment was, that patients reco- 
vered more rapidly from the disease than w T hen any other plan was pursued. 
This was most important, particularly in Paris, where bleeding was often resorted 
to, to a considerable extent, and patients were consequently kept months, and 
even years, in a weakly condition. He had never seen any injurious effects from 
the large doses given. This, no doubt, w r as owing to the large quantity of fluid 
in which the medicine was dissolved. In all cases of poisoning by this agent, re- 
corded in works on medical jurisprudence, the quantity of fluid used was small. 
He (Dr. Bennet) had recorded some cases treated by this medicine, in the Lancet 
of 1845. The plan pursued was perfectly original, and the originality was due to 
Dr. Basham. In slight rheumatic cases, in which there was little febrile action, 
this treatment was most beneficial, the patients recovering in four or five days. 

Dr. Basham said, that in only two cases had he treated the disease by nitrate of 
potash alone. The acute, inflammatory symptoms usually gave way on the third 
or fourth day; and it was important to state, that in no one case treated by the 
nitrate of potash had there been any relapse. This was a strong recommendation 
of the value of the treatment, when we recollected how common relapses were, 
when the other modes of treatment were employed. In the first instance, he had 
given as much as four ounces of the salt in the twenty-four hours, but he had now 
reduced the quantity to one or two ounces in that period. A great quantity of the 
salt escaped by the urine, the quantity of w r hich was not much increased, but its 
specific gravity was a great deal higher, averaging between 1030 and 1040. This 
increase in the specific gravity he considered was due to the potash. — Lancet, Nov. 
25, 1848. 

32. Collodion in the] Treatment of Diseases of the Skin. — By Erasmus Wilson. Esq. 
(Lancet, Nov. 18, 1848.) — The author first employed this article in a case of scrofu- 
lous ulceration of the skin, and from careful observation of its effects in that case 
found it to possess four important properties, viz. 

First. That of a mild stimulant. 

Second. That of an efficient substitute for the natural scarf-skin, 
Third. That of a mechanical compress. 

Fourth. That of an adhesive glue, from which quality it derives its name. 

First. As a mild stimulant, it is fitted to exert a local alterative action on the 
congested capillaries of a chronic ulceration, and give activity to the healing 
process. 

Second. In its character of a substitute for the absent scarf-skin, it is transparent, 
pliant, and more or less impermeable, according to the thickness of the layer thai 
may seem to be required. 

Third. Its most remarkable properly, as it seems to me. is the contraction which 
occurs during the dessication of the collodion, and which produces a local pressure 
of considerable power on the surface to which it is applied. Thus, in the case 
above related, the congestion of the thickened skin was relieved by the varnish- 
like film of collodion spread upon its surface, by means of a camel-hair brush, as 
completely as if a nicely-adjusted bandage had been placed over it. In another 
instance, 1 found a film of collodion entirely remove a purple congestion (result- 
ing from imperfect circulation) from the tip of the nose, in a lady who had long 
suffered from the annoyance. In a third case, in which the fingers of an elderly 
lady were congested and blue, and the congestion was attended by pain and 
throbbing, like that which accompanies chilblains, the collodion produced so 
much contraction as to render their tips white and bloodless, and I was obliged to 
discontinue the application in consequence. 

Fourthly. The glue-like property of the collodion is evinced in its adhesion of 
cut surfaces, a property which is much increased by the contraction above men- 



186 



Progress of the Medical Sciences. 



[Jan. 



tioned. When employed with the purpose of keeping together the edges of an 
incision, a piece of cambric or thin linen rag should be dipped in the solution, 
and placed along the line of incision, after the cut edges have been adjusted and 
carefully dried, perfect dryness of the skin being a necessary condiiion to the ad- 
hesion of the solution. From the rapidity with which the solution dries, and its 
perfect adhesive powers, collodion is likely to occupy an important place among 
the "adjuvantia" of surgical practice. 

The diseases of the skin in which Mr. Wilson has hitherto used the collodion 
with advantage are, chronic erythema of the face ; intertrigo; chapped nipples 
and chapped hands; herpes labialis, prepuiialis, and herpes zoster; lichen agrius; 
lupus non exedens and exedens; acne vulgaris; and several affections of the sebi- 
parous organs. In chronic erythema of the face, its contracting power was most 
usefully evinced, as it was also in lupus non exedens, and acne. 

In a troublesome case of chapped hands and fingers, resulting from chronic 
lichen agrius, the collodion acted not merely as a protective covering, but also 
promoted the healing of the cracks more quickly than the remedies Mr. W. has been 
in the habit of employing. In chapped nipples, it was even more efficient in its 
protective and curative action, and seemed, in the two instances in which he used 
it, to work a charm upon the painful skin. The gaping cracks were instantly 
drawn together and almost obliterated by the contracting power of the remedy, 
and were effectually shielded from the influence of moisture and the pressure of 
the gums of the infant, and all this, in consequence of the rapid evaporation of 
the ether, in an instant of time. In another point of view Mr. W. considers the 
remedy invaluable as an application to chapped nipples — namely, as being in 
nowise injurious to the infant, from offering nothing which can be removed by the 
lips during the act of sucking, and in this particular, therefore, possessing a vast 
superiority over the various forms of ointments, astringent lotions, &c. 

In four instances, it immediately put a stop to herpes labialis, and in a very 
severe attack, it showed itself to be a powerful and useful remedy. Small super- 
ficial ulcerations of the corona glandis and prepuce, caused by excoriation, were 
cured by a single application, and in a gentleman very susceptible of excoriation, 
it acted admirably as a prophylactic. From the success of the latter trial, Mr. W. is 
inclined to think that it might be usefully employed as a prophylactic, in cases of 
exposure to syphilitic contagion. 

When properly applied, the collodion enters afHhe crevices of the lines of mo- 
tion of the skin, and adheres so firmly as to require several washings for its re- 
moval. As it is usually prepared, it has the consistence of syrup, and in this state 
is best suited for those cases in which its adhesive properties are principally 
needed. Where, however, it is intended to be applied to the surface of an ulcer 
or abrasion, or to chaps of the skin, Mr. W. finds it convenient to dilute it with ether, 
and render it almost as limpid as water. 

In pursuing this subject, Mr. W. has made trial of a solution of gutta percha in 
chloroform, and also in benzole, but these solutions he has found very inferior to 
the collodion, for the purposes above named. 

33. Epilepsy cured by cauterization of the Sinciput. — Doctor Lebreton relates in 
the Gazette Medicate de Paris (30th Sept. 1848), a case of epilepsy of eight years' 
duration in a person 21 years of age, cured by five or six applications at intervals, 
of the actual cautery to top of the head, along the sagittal suture. The cauterizing 
iron was two lines in diameter, and the whole thickness of the skin was im- 
plicated. 

34. Arsenic in Furunculus and Acne. — Dr. Schweich has prescribed arsenic 
with great success, in various cases of furunculus that have come under his care 
for some time past, and has found the cure very durable, and the use of the me- 
dicine, during which the ordinary diet may be continued, attended with no in- 
convenience. He begins with four drops of Fowler's solution forenoon and after- 
noon, until a drachm has been taken, and then gives five drops until the second, and 
six drops until the third is attained, and so on. Acne simplex, in which the knotty 
pustular appearance of the eruption gives it the character of a miniature furuncle, 
and which is often so obstinate, and, when attacking the face of young people, 



1849.] 



Medical Pathology and Therapeutics. 



187 



so annoying, yields as readily to the arsenic. The injurious effect of aperients 
in these affections leads to the supposition that the source of the dyscrasis is a 
specific irritation of the alimentary canal, which is only augmented by the stimulus 
of purgatives, especially the saline. — Brit, and For. Med.-Chir. Rev.) Oct. 1848 ; 
from Casper's Wochmschrift. No. 6. 

35. On the. Use of Stomachics in Dyspepsia. — Your heavy feeder's safety lies in his 
dyspepsia: cure this and you kiil your patient. The man who takes five times 
too much nourishment into his stomach, would die at once, if the digestive system 
would convert it into five times too much blood. He that habitually overfeeds; 
suffers from a dyspepsia, which prevents more blood than is necessary being ela- 
borated, and is much more frequently the cau.-e of a deficient supply. A certain 
quack medicine once obtained an extensive reputation for the cure of gout. The 
Duke of Portland, whom it had benefitted, bought the recipe for two thousand 
guineas, and made it public. Hence, it was long known as the Portland powder. 
All who suffered from gout or dyspepsia, fortified their stomachs for the pleasures 
of the table with this medicine, and agreed that they never felt better or enjoyed 
themselves more. Somebody, however, at length discovered that no one lived 
long, after being cured by the Portland powder. All died in the course of two or 
three years, of apoplexy, or an attack of acute inflammation. The tonic action of 
the bitter ingredients of this medicine had enabled the digestive system to elaborate 
a larger supply of blood than was necessary, and the brittle vessels of the brain 
were burst by the distension to which they were subjected, whilst a predisposition 
to acute inflammation arose from a redundance of organizable material. — Prov. 
Med. and Surg. Journal, Oct. 1848. 

36. Belladonna in the Nocturnal Incontinence rf Urine in Children. — M. Trousseau 
narrates the case of a girl, five years old, who, since her third year had been the 
victim of this obstinate complaint. No effort was neglected on the part of the 
parents to remove the habit; but all the means adopted — some of them sufficiently 
severe — were without effect. A pill, containing one centigramme of the powder 
and half a centigramme of the extract of belladonna, was ordered to be taken 
every night at bed-time. During the first week two nights were passed without 
accidents* and from that time, with two or three exceptions, the complaint entirely 
disappeared. The treatment was resumed from time to time for nearly a year. 
This is only one of several cases occurring, as well in his own practice as in that 
of M. Bretonneau, in which Professor Trousseau has observed marked benefit 
from the use of this drug — VUnion Med., Oct. 14. 1848. 

In a more recent number (Oct. 21) of the same journal, Dr. Blache, physician 
to the Hopital des Enfans, records two very obstinate cases of nocturnal inconti- 
nence of urine occurring. in individuals, one fifteen and the other eighteen years 
of age, where mercurial and sulphurous baths, refrigerant and astringent applica- 
tions, tonic and ferruginous medicines, tannin, er^ot of rye, nux vomica, and all 
other means had failed. Ultimately belladonna was exhibited with complete suc- 
cess. — Monthly Relros., Dec. 1848. 

37. Local Application of Chloroform in Lumbago. By M. Moreau. — Three cases 
of this disease are detailed in which immediate and permanent relief was obtained 
by the application to the loins of a piece of lint on which some chloroform had 
been poured. Oiled silk ought to be laid above the lint, to prevent the evaporation 
of the chloroform. In a few minutes the patient complains of a burning heat in 
the part, which becomes red, and occasionally vesicles are formed : at the same 
time the rheumatic pain disappears. The author thinks that the cure cannot be 
attributed solely to the counter-irritation, as in one of the cases recorded sinapisms 
had been previously employed, without success. He supposes the chloroform to 
reach by imbibition the cutaneous and superficial muscular nerves, on which it 
exerts its anaesthetic power. — Monthly Rctros.. Dec. 1848, from L' Union Medicate, 
Oct. 21. 1848. 

38. Local Application rf Chloroform to a Pelvic Tumovr. By M. Legroux. — Tn a 
case of pelvic tumour, where the patient suffered from severe pains of the inferior 



188 



Progress of the Medical Sciences. 



[Jan. 



extremities, probably in consequence of the nerves being compressed in traversing 
the pelvis, the usual means of affording relief having failed of success, M.Legroux 
determined to try the local application of chloroform. A sponge containing chlo- 
roform was placed in the foot of a large boot of wax-cloth, constructed for the 
purpose, so that the vapour only came into contact with the skin. A feeling of 
warmth, prickling, and numbness, was soon experienced. The application was 
continued for several hours; when complete, ansesthesia was established, and the 
neuralgic pains had entirely ceased. The absence of pain continued several days, 
and the same treatment was equally successful on its return. — Ibid., from Ibid., 
Oct. 31, 1848. 

39. Case of Hydrophobic Mania successfully treated with Chloroform. By R. Y. 
Ackerley, Esq. — John L , a labourer, aged thirty, of a phlegmatic tempera- 
ment, had been residing for about a fortnight in his house by himself, (his wife 
having gone into the country with a sick child, for change of air:) and had been 
complaining of not feeling quite well for a week or ten days; his general habits 
were very quiet, sober, and peaceable, but for the last few days he had been ex- 
ceedingly irritable towards his fellow workmen. Between ten and eleven years 
ago he had been bit in the leg by a rabid cat, and the wound had been cauterized 
with a hot iron at the time. His general health had been very good. 

On the 14th of January, when his wife returned, he complained of lowness of 
spirits and a giddiness in his head: passed a very restless night; said he feared he 
was going to lose his senses, occasionally mentioned the bite of the cat, and attri- 
buted his illness to that cause, examining at the same time the cicatrix on his leg. 
He did not go to work on the following day, but rambled, and said he feared that 
something dreadful was going to happen to him; took his food well; had frequent 
flushings in the face, with occasionally a feeling of coldness in the back, but no 
distinct rigor, nor headache. He got some medicine from a druggist, which purged 
him; the evacuations were very dark; had no sleep all night. 

On the following day (Saturday) he thought himself rather better, felt hungry, 
and wanted breakfast and dinner early, of which he partook freely; at supper he 
could not eat, but looked wild, and rambled in his conversation. At eleven P. M. 
my assistant, Mr. Bryde, saw him: his tongue was red and moist; pulse 95; skin 
hot and dry. Ordered five grains of calomel immediately, to be followed by a 
saline febrifuge mixture every four hours, and a blister to the nape of the neck. 
Had restless sleep during the early part of the night, but none towards morning; 
took his medicine regularly during the night, but towards noon was unable to 
Bwallow liquids, which were rejected with great force by a spasmodic action of 
the muscles of deglutition. He refused drink during the remainder of the day, 
bui took his medicine from me in the evening with great difficulty. After sleeping 
about two hours, he was more calm, but not quite collected ; is constantly rambling 
about a cat; fancies he sees one in the room, and asks his brother to kill it. Pulse 
90 and soft; skin hotter than natural; complains of a heavy beating and shooting 
pain about the diaphragm, and giddiness in the head; is constantly wiping a viscid 
saliva from his mouth ; the eye very wild ; he shrinks under the bed-clothes when 
spoken to, and tries to hide himself. I examined the leg and found the cicatrix 
quite natural; tried every means to banish the idea of hydrophobia from his mind. 
Ordered extract of Indian hemp, five grains every four hours. 

January 18th. Has passed a better night; appears very sullen, and either unable 
or unwilling to answer any questions; frequent flushings of the face, and a horror 
of fluids when offered to him; at my request he attempted to drink a little tea, 
but when he got it into his hand he turned from it with dread. Has taken nothing 
but his medicine during the night; pulse 92; tongue red, but not dry; slight epi- 
gastric tenderness; skin cool; pupils dilated; conjunctivae not at all injected. The 
Indian hemp to be continued. — Three P. M. : sullenness increased ; will not answer 
any questions, and refuses everything offered to him; in other respects much the 
same as in the morning. Every precaution was now taken that he should not do 
any injury to himself or others, as it was feared that furious mania might super- 
vene. My friend, Mr. Bainbrigge, met me in consultation at ten P. M. Has taken 
his medicine better, and also a cup and a half of tea, which he sucks through his 
teeth; he still refuses to answer any questions. 



1849.] 



Medical Pathology and Therapeutics. 



189 



19th. Sleepless night; he talks of the cat, and attributes his illness to that cause, 
but still will not speak when spoken to. Bowels constipated; tongue dry and red. 
Ordered calomel, ten grains, to be taken immediately. 

20th. No sleep all night; left eye injected ; the spasmodic contractions of the 
muscles, which at first were confined to the throat, have now extended 1o the limbs, 
the elbows being drawn very much backwards towards the spine; the wrists and 
feet also distorted. Has been very violent during the night, requiring the assist- 
ance of four men to hold him, and shouting and struggling incessantly. 

We now came to the determination of trying the chloroform, which put him to 
sleep in about three minutes; he did not awake again for three-quarters of an 
hour; when he appeared much more calm, recognised his wife, and kissed and 
embraced her; deglutition better ; the bowels had not acted; pulse ninety. To 
have four ounces of infusion of senna, and a blister over the scalp; in the evening 
we found him much quieter: the bowels had acted; passes his urine and stools 
involuntarily. The effect of the chloroform was so decided in the morning that 
we resolved to repeat it, which was accordingly done with the same beneficial 
effect. The cerebral symptoms, however, returned about one in the morning, and 
at our visit at ten o'clock on the 21st, we found him a perfect maniac; conjunctivae 
of both eyes much suffused; dilatation of pupils; skin cool; no unnatural action 
about the carotids: spasms of the limbs increased, and extending to the muscles 
of the spine, producing occasionally a state of opisthotonos. The chloroform was 
again administered, and he remained very quiet during the day, sleeping at inter- 
vals. The chloroform was used again in the evening. The emaciation was very 
marked, and to a greater extent than we had ever seen it in any other disease of 
the same duration. He was ordered wine and brandy, with arrow root and beef-tea. 

22d. This morning we found him worse again; total deprivation of all his 
mental faculties. Ordered an ointment of tartar-emetic and croton oil, to be rubbed 
over the whole extent of the spine. Ice to be. applied to the head, and to have 
the chloroform. In the evening, symptoms somewhat better : chloroform repeated. 

23d. Has passed a more comfortable night: the conjunctivas less suffused; 
countenance more intelligent; tongue becoming moist and less red; pulse ninety- 
four; bowels constipated. Ordered one drop of croton oil, every four hours; chlo- 
roform repeated. — Evening: appears better in every respect; the bowels have 
acted. Ordered muriate of morphia, one grain, to be taken immediately : and. 
chloroform. 

24th. Had several hours' sleep, and is more sensible ; complains of his hands 
and feet feeling cold. The ice to be discontinued, and. to have hot water to the 
feet. Ordered chloric ether half an ounce, carbonate of ammonia half a drachm, 
camphor mixture seven ounces and a half. Mix. An ounce to be taken every 
three hours. — Evening : better in every respect, except that the pulse has got up to 
120; this might be attributed to his having had too many of his friends seeing 
him. Gave the chloroform, and in fifteen minutes we found the pulse had come 
down to eighty-eight. Repeat the morphia and mixture. 

25th. Has had an excellent night; returning intelligence; pulse ninety-four; 
skin warm ; still passes his urine and stools under him ; expression of countenance 
improving. From this time the improvement was so rapid and continuous that I 
shall not consider it necessary to describe the symptoms daily. The chloroform 
was administered occasionally, with tonics and stimulants; and in about a fort- 
night he went into the country, quite well both in mind and body. — Lancet, July 
29th, 1848. ; * 

40. Use of Chloroform in Insanity. By Dr. M'Gavin. — The importance of the 
subject induces us to give entire the following remarks on cases in the Montrose 
Lunatic Asylum : — The introduction of chloroform, immediately after the nature 
of this wonderful asjent became known, has constituted the only new feature in 
what may be styled the purely medical part of the treatment. Its beneficial effects 
have been conspicuous in many cases in which it has been used during the latter 
part of the last year. The first two patients selected for experiment with the 
chloroform, were the most noisy and excited in the establishment. One laboured 
under acute mania; the other was a decided melancholic. In the first case, all 
the ordinary and approved means for calming excitement and allaying irritability 
No. XXXIII.— Jan., 1849. 13 



190 



Progress of the Medical Sciences. 



[Jan. 



had been, for two or three days, steadily persevered in without much benefit. It 
then occurred to me that chloroform might be tried. The patient was accordingly 
secured, which, by the way, was not a very easy task, and the inhalation com- 
menced. The first inspiration was succeeded by a struggle j but this resulted more 
from dread on the part of the patient that some mischief was to befall him than 
from any other cause. After a few more inspirations, he complained of sickness ; 
and in less than a minute and a half from the commencement of the inhalation, 
the functions of the brain were completely suspended. He remained in the 
comatose state for a minute or two alter the withdrawal of the vapour. While 
recovering from his state of unconsciousness, he looked confused, and reeled about 
the room like a person under the influence of some intoxicating liquor. In a short 
time he completely recovered from the immediate effects of the chloroform, but its 
soothing influence was conspicuous for the greater part of the day. He became 
drowsy — slept a short time — and was afterwards less excited, and more collected 
and rational than he had been since his admission. The chloroform was exhibited 
from time to time in this case, and sleep almost invariably followed. The patient 
ultimately got better. The second patient operated on was a woman possessed 
of a strong suicidal tendency, who had been moaning and crying incessantly for 
days and nights without intermission. She had not been observed to sleep for 
nearly seventy-two hours. The chloroform was exhibited in the usual way, and 
very soon reduced her to a state of unconsciousness. On recovering, she com- 
plained of sickness, and vomited ; after which she was, at her own request, placed 
in bed, where she enjoyed a sound and refreshing sleep for upwards of three 
hours. So sensible was this patient of the benefit she derived from the chloro- 
form, that, when afterwards agitated and overwhelmed with despair, she would 
implore the medical superintendent to repeat the exhibition. In this she was often 
indulged. In the first case alluded to, I have very little doubt that the chloroform 
had a considerable share in conducing to recovery, or, at least, that it paved the 
way by suspending the functions of the brain, and thus affording rest to its sub- 
stance. No doubt the same thing is accomplished in similar cases, and might 
have followed in this case also, by the exhibition of sedatives and hypnotics: but 
before sleep is procured in this way, days and weeks sometimes intervene. The 
rapidity with which the chloroform acts, and the consequent saving of time to the 
physician, and of nervous energy to the patient, are strong arguments in its favour. 
It is difficult to say & priori, how far the prolonged exhibition of chloroform may 
be useful in correcting morbid trains of thought in cases of insanity unattended 
with excitement. Experiments, with a view to the solution of this question, 
could not but prove interesting. — Monthly Journ. and Retrospect Med. Sci.. Oct., 
1848, from Dr. M 'Gavin's Report of the Montrose Lunatic Asylum, 1848. 

41. Insanity cured by Sulphate of Quinine. By M. Piorry. — Four cases of mania 
are reported, in which a complete cure was effected in periods varying from 
twenty-four to forty-eight hours, by the use of this medicine. The cases were re- 
cent and acute ; they were characterized by various sensory illusions, and by the 
occurrence of a paroxysm about the same hour every evening. We give the de- 
tails of one case. 

A woman, thirty-five years of age. was brought into the hospital in a state of 
furious delirium, which rendered necessary the use of the strait-jacket. She 
imagined that she heard the voices of several persons constantly talking be- 
side her. and in particular of an individual who had excited her jealousy, and of 
whom she wished to rush in pursuit. The attendants were obliged to tie her 
down in bed, and the house-surgeon proposed sending her to the Salpetriere. 

Two days afterwards, M. Piorry saw her at his morning visit, and found her 
very irritable, but succeeded in getting from her some account of her complaint. 
Her disease commenced with noises in the ears and imaginary voices, followed 
by delirium, of which she was herself sensible. All these symptoms were much 
aggravated at night. She was ordered fifteen grains of quinine; no other treat- 
ment. Next day there was no delirium, and the day after she was perfectly well. 

These cases are very remarkable from the rapidity with which they were cured. 
M. Piorry considers the delirium of insanity as often induced by certain abnormal 
sensations, and functional derangement of the organs of sense ; and of other parts 



1849.] 



Surgery. 



191 



of the system. Tn this point of view, it is analogous to various nervous and neu- 
ralgic complaints, which are frequently periodic in their attack. Periodicity, in- 
deed, according to his view, is the normal mode of action of the nervous system, 
and it is therefore not improbable that certain morbid phenomena should obey 
the same law. In such cases, quinine is indicated from its anti-periodic powers. — 
Monthly Jour a. and Retrospect Med. Set., from Gazette des Hopitaux, Aug., 1848. 



SURGICAL PATHOLOGY AND THERAPEUTICS AND OPERATIVE 

SURGERY. 

42. Ligature of the Primitive Carotid Arlery for an Aneurismal Tumour in the 
Temporal Region. — M. Barrier has recorded in the Joum. de Med. de Lyon a 
case of aneurismal tumour in the temporal region in a woman thirty years of age, 
resulting from a blow. When the patient was admitted into the Hotel Dieu of 
Lyons, the tumour was of the size of three-fourths of an orange, and extended 
from the ear to the angle of the eye ; it was pulsatile, its pulsations ceasing on the 
compression of the temporal artery towards its origin, or more completely when, 
the primitive carotid was compressed. M. B. tied the primitive carotid on the 
3d of November; demiaphonia and difficulty of deglutition supervened, but 
both ceased on the third day. The ligature came away on the thirteenth day. 
On the 10:h of December, the date of the last report, it is stated that the wound 
had almost entirely healed : the tumour had decreased in volume and there was 
no pulsation in it: and all cerebral symptoms had ceased. — Gaz. Med. de Paris, 
30th September, 1S48. 

43. Strangulated Hernia, reduced by Fright. — M. Cabaret reports in the Journal 
de Montpelier. a case of strangulated inguinal hernia, in a man thirty-five years 
of age. which, having resisted all means of reduction, it was determined that an 
operation was necessary. The patient was excessively alarmed on this being 
announced to him. The skin over the tumour was shaved, a fold drawn up, and 
an incision was about to be made, when the patient fell into a sudden collapse. 
Mi C, looking then at the tumour, perceived a movement in it, and on placing 
his hand on it, found that reduction had spontaneously occurred. The patient 
speedily revived under the use of stimulants and a rapid cure was accomplished. 
— Gaz. Med. de Paris, Sept. 23, 1848, from Joum. de la Societe de Bled. Pratique 
de Montpelier. 

44. Application of Laudanum in Orchitis. — It is well known that the pain which 
attends the acute stage of .orchitis and blennorrhagic epididymitis is most intense. 
M. Yoillemier einplovs the following treatment which relieves those pains when 
most intense, in a few hours. He envelops the inflamed testicle in a compress 
dipped in pure laudanum, and covers it with oiled silk. In three or four hours 
the organ is narcotized: the pains cease and the inflammation always rapidly 
abates^— Gaz. des Hopitaux, July 8th, 1848. 

45. Rigidity of the Rand nfter Fracture of the Forearm. — M. Hervez de Che- 
goin observes, that owing to the compression used in the treatment of fractures of 
the forearm, and the prolonged extension of the fingers, the patient often remains 
with an impaired mobility of the hand and fingers, which places him in a worse 
slate than if no treatment whatever had been employed. Indeed, on this account 
M. Yelpeau has abandoned the use of apparatus in these fractures. 

The manner in which the author treats these cases, so as to prevent rigidity, 
is as follows: — In those in which there is no displacement he merely lays the 
forearm on a somewhat solid surface ; but where there is a constant tendency to 
the reproduction of the displacement, he places it on a very thick and firm 
cushion, terminating opposite the bend which separates the hand from the arm — 
bring it more or less near this bend, accordingly as the lower fragment projects 
forwards or backwards ; so that in the first case it is this fragment which is brought 
against the cushion, and in the other, the lower extremity of the upper fragment. 



192 



Progress of the Medical Sciences. 



[Jan. 



The hand is allowed to hang down in front of, and below, the cushion. On the 
twelfth day a splint and compress four inches long are substituted, and kept on 
by two broad tapes tied over a single pad on the back of the arm, so as to avoid 
all constriction. If there is displacement towards the interosseous space, a 
compress may be there interposed. Entire consolidation takes place towards 
the thirty-fifth day, and, in consequence of the absence of injurious compression, 
neither gangrene, muscular atrophy, nor adhesions occur, and tedious convales- 
cence and imperfect recovery are avoided. — Brit, For. Med. Chirurg. Rev., Oct. 
1848, from L' Union Medicate, No. 46. 

46. A New Mode of Performing Lithotomy by the Rectum. By M. Maisonnetjve. — 
An interesting case has been recently published, in which the operation performed 
by Sanson and Vacca was advantageously modified. After placing the patient 
(set. 28) in the ordinary lithotomy position, and giving the catheter (with a very 
large groove) in charge of an assistant, M. Maisonneuve, standing between the 
thighs, lodged the nail of his left index-finger, passed into the rectum, in the 
groove of the catheter, just anterior to the prostate. Along this finger he next 
slid a pointed bistoury, guarded by lint to within a centimetre of its end, and 
made a small incision through the rectum and membranous portion of the 
urethra. Still retaining his nail in the groove, he next passed a double lithotome, 
Avith its concavity upwards, and having assured himself of its secure implanta- 
tion in the groove, withdrew his index-finger, took hold of and slightly raised the 
catheter with his left hand, while with his right he opened the bladder with the 
lithotome. The catheter was now withdrawn, and the right hand so turned as to 
bring the concavity of the lithotome backwards. Next he introduced the index 
and middle fingers of the left hand above the lithotome, and separated the one 
from the other, so as to dilate the rectum and protect the sphincter while he with- 
drew the lithotome, the blades of which, separated fourteen lines from each 
other, made a bilateral incision in the prostate and rectum. The forceps were 
then passed along the fore-finger, and the stone removed. 

The patient recovered so rapidly, as to be sitting in the yard on the fourth day, 
and he w T as exhibited at the academy after a long walk, on the ninth. A 
urinary fistula still remained when he returned to the country on the seventeenth 
day, but this subsequently healed. This operation differs from that of Sanson 
and Vacca by leaving the lower end of the rectum, the sphincter, and the 
perineum untouched; and this prevention of the exposure of the wound to 
external influences, places it very much in the same category with the subcuta- 
neous incisions. — Brit. § For. Med. Chirurg. Rev., Oct. 1848, from L'Union Medicate, 
No. 63. 

47. Reduction of a Dislocation forward of the Inferior Surface of the Fifth Cervical 
Vertebra. By M. Vrignonneau. — The patient fell from a tree, on his head, and 
lost consciousness, which, however, returned in half an hour; he then complained 
of violent pain at the vertex and back of the neck; the author diagnosed — how, 
he does not say — a dislocation forwards of the inferior surface of the filth cervical 
vertebra. He bled the man, and ordered absolute rest, but without avail ; and forty 
hours subsequently — speech having become difficult, the face injected, the respi- 
ration stertorous and the pulse almost imperceptible — he determined to give him 
the chance of an attempt at reduction. For this purpose the man was seated, two 
assistants pressing firmly, one on each shoulder, while M. V. gently extended the 
neck. Partial extension rendered the speech stronger, and respiration freer, and. 
emboldened the operator to proceed further. When he thought the extension suf- 
ficient, he carried the head and superior part of the neck backwards; this manipu- 
lation was followed by a snap, and from that moment the man recovered as by 
enchantment. The patient at the date of the report had returned to his work, but 
there still remained some rigidity of the neck, and lateral motion especially is very 
limited. — Journal de Connaiss. Medico- Chi r., Jan. 1848. 

48. Vertical Dislocation of Patella. — M. Debrou relates a case of this rare 
accident. It happened to a man of sixty, who got his leg entangled in a cart 
wheel; when raised he could not stand upright. His appearance was as follows: 



1849.] Surgery. 



193 



— The knee was flexed to within a third of a right angle; extension incomplete, 
and painful ; the anterior aspect of the joint very prominent, on account of the new 
situation of the patella, which, moreover, was immovable. M. Debrou reduced 
it in the following manner : — One assistant holding the thigh, another held the leg 
and raised the heel, so as to extend it upon the thigh, which was flexed upon the 
pelvis. M. Debrou standing on the exterior of the leg, supporting the posterior 
aspect of the joint with the left arm, forcibly pushed the patella inwards with the 
palm of the right hand; the bone, after a continued effort, slipped into its place. 

49. Disease of the Appendix Cceci cured by Operation. — Dr. Hancock related to the 
Medical Society of London (Sept. 25th, 1848) the following case, which he ob- 
served appeared to be of value, from its presenting a mode of treatment which 
might be advantageously pursued in certain stages and forms of mischief result- 
ing from the presence of impacted feces or foreign substances, either in the ca> 
cum or its appendix, which have hitherto for the most part, if not invariably, 
proved fatal. He said that abscesses of the abdomen connected with the caecum 
or large intestines, and attended with fluctuation, had, from time to time, been 
opened; but he was not acquainted with any instance in which an operation had 
been attempted under the circumstances detailed in the following case, and where 
the result had been so entirely satisfactory. In the cases recorded, the presence 
of fluctuation has proved the existence of matter; but the following detail will 
show that we should not always wait for this unequivocal sign. Patients do not 
always live until the disease has progressed thus far; they frequently sink and die 
without any further symptoms than those of inflammation of the part; and it is to 
this class of cases that the treatment here related appears to me most applicable. 
I was requested, on Saturday, 15th of April, 1848, to see a lady, aged thirty, in. 
consultation with Dr. Chowne and Mr. Diamond. She was of delicate constitu- 
tion, having been a seven months 7 twin. She, about twelve years since, received 
an injury to the spine whilst playing at cricket with her brothers, which confined 
her to her bed for about nine months. Eventually, the only bad symptoms re- 
maining were partial paralysis of the lower intestines, so that the bowels were 
never effectually relieved without the aid of an enema, and severe occasional 
attacks of pain, for which she took large doses of laudanum. She married about 
five years after the receipt of the injury, and her pregnancies have always been 
attended throughout with violent sickness and ill health. In April 1848, she was 
pregnant with her fifth child ; the sickness had been most violent and distressing 
during the whole time, opium, hydrocyanic acid, and the usual remedies failing 
to give her any relief. On the 3d, after riding out for an hour, she felt an unusual 
dragging, and pain in the right side, obliging her to keep her bed, and to take 
opiates. On the seventh she was suddenly seized with labour, and delivered of 
a small male child six or seven weeks before the fall time, which only lived 
about twenty hours. The next day, the 8lh, whilst turning in bed, she felt a se- 
vere pain in the groin, as she described, as of something having snapped asunder, 
and from that time she continued to suffer greatly in the whole inguinal region; 
but as the pulse continued about ninety, and there was no particular tenderness on 
pressure, nothing was done but the administration of sedatives. On the 10th, the 
pain was more acute, and a slight hard swelling could distinctly be traced high up 
in the inguinal region; bowels had been slightly relieved by the enema. Six 
leeches were applied over the spot, and subsequently warm fomentations, which 
were also applied over the labia, the lochia having ceased, and the urine being 
very scanty. She continued much the same until the 13th (a blister having been 
applied on the 11th): the cord-like swelling could now be felt more distinctly, and 
the tenderness extended over the whole abdomen. On the 14th, Dr. Chowne 
first saw her in consultation. Her tongue was brown; pulse about ninety; ten- 
derness and pain the same: bowels not relieved by the usual enema. A dose of 
six grains of calomel was prescribed for her, to be followed by three grains ev ery 
two hours, until she had taken twelve grains. At the end of twelve hours the 
bowels were only slightly acted upon by enema. Fomentations continued, with 
saline and opiate mixture. I first saw her on the 15th ; she was then complaining 
of intense pain in the riizht inguinal region; could not bear any pressure on that 
part; the whole abdomen, which was tympanitic, was tender on pressure, but 



194 



Progress of the Medical Sciences. 



[Jan. 



not sufficiently so to be very urgent. She had observed a swelling in this situa- 
tion before her pregnancy but previous to her confinement it had not caused her 
any uneasiness. From the slight examination which, on account of the soreness 
of the blister, I was enabled to make, I was disposed to suspect mischief about 
the caecum, or its appendix, but as the symptoms were not very urgent, it was 
agreed to continue the opiates, and apply poultices over the part until we met 
again on the 17th. 

April 16. Not so well; pain more acute; more decided signs of peritonitis. 

17th. Much worse than when we last saw her. Her countenance anxious; 
nose pinched; pulse intermittent and running; sickness very troublesome : tongue 
brown in centre; had obtained no sleep, although thirty doses of the solution of 
bi-meconate of morphia had been given every three hours. Skin cold and 
clammy ; complained of great pain, and fits of shivering, which were most violent, 
and from their frequency had prevented her sleeping; bowels scarcely relieved by 
enema. 

The blistered surface having healed up, a more decided examination could be 
made. The cord like swelling already alluded to was more apparent, but too 
close to the spine of the ilium to be an inguinal hernia ; there was also thickening 
with hardness extending outwards towards the ilium, where she complained most 
of pain. As she was evidently sinking, and the previous treatment had been of 
no avail, 1 proposed to make an incision from the spine of the ilium to the inner 
side of the internal abdominal ring over the hardened spot, so that if it were in- 
testine or omentum it could be freed: or if, as we thought more probable, matter 
had collected in the right iliac fossa, it could be let out, and thus give our patient 
a chance of recovery. This having been agreed to by Dr. Chowne and Mr. Dia- 
mond, who attended the case with me throughout, the patient was put under the 
influence of chloroform, and an incision about four inches long made inwards 
from the spine of the ilium above Poupart's ligament, but as close to it as possible. 
Upon opening into the abdomen, a quantity of excessively offensive turbid serum, 
with fibrinous flocculi, poured out. mixed with air globules, and also patches of 
false membrane. She was directed to be turned on her side, that the discharge 
might freely escape; a poultice to be applied, and to take an opiate. 

We again saw her at ten o'clock that evening; her abdomen was then very 
tympanitic and painful; pulse 120; skin, however, warmer than before the ope- 
ration; the wound has discharged very freely, the fluid being most offensive. 

To take morphia with carbonate of ammonia every four hours, and to have a 
starch enema, with five drachms of sedative liquor of opium. 

18th. Better; has passed a more quiet night; wound discharges freely a turbid 
serous fluid; bowels have been relieved by enema. Tongue white; pulse 120; 
suffers from spasmodic twitchings of body. Abdomen very tender over the whole 
surface, and slightly swollen. 

To continue the sedative draughts, each containing sixty minims of the solution 
of morphia every three hours, with starch enema, with six drachms of solution of 
opium at night. 

May 1st. Has gone on favourably up to this date; the opiate enemata have 
been omitted, but the opiate draughts continued, with occasional small doses of 
calomel, which have greatly controlled the sickness. She has been allowed as 
much nourishment as she will take, but her appetite continues bad. She has also 
had wine, brandy, and bottled stout from time to time, the discharge being large 
in quantity, thin, watery, and very offensive: the abdomen has become soft and 
painless on pressure. To-day she is not so well, suffering great pain about the 
wound, which is inflamed, and the edges sloughy. Ordered warm fomentations 
to be applied continually over the whole surface of the abdomen. 

2d. tier sleep has been much disturbed by acute pain around the wound ; dis- 
charge thinner, greenish, and very offensive. Upon carefully examining the 
wound, a small round ball of fecal matter, surrounded by calcareous deposit, was 
discovered, and upon further examination, a second piece excavated on one side, 
evidently forming a cup for the former piece, and which, from their size, I should 
imagine had been impacted in and escaped by ulceration from the appendix ver- 
miformis. A large quantity of hard feculent matter passed per anum ; after the 
enema. 



1849.] 



Surgery. 



195 



To continue the nourishing diet; and, as profuse perspirations have come on, 
to take disulphate of quinine, with sulphuric acid, and infusion of roses with opiate 
at bed-time. She got well from this dale; the discharge gradually improving in 
quality. 

In some remarks upon this case, Mr. Hancock referred to the frequency of 
operations on the abdomen of late, particularly in cases of ovarian disease, many 
of which had been successful. As far as he knew, the instance related was the 
only one on record of an operation of the kind, under the circumstances delailed. 
He should not argue, or draw general conclusions from a solitary case, but he 
thought that it, at all events, would justify us in having recourse to such a pro- 
cedure in cases of peritonitis, when all other means had failed, and without which 
death was inevitable. He contended that the typhoid condition into which pa- 
tients affected with peritoneal inflammation fell, did not depend upon the violence 
of the disease, but upon the acrid nature of the effused fluid, the removal of which 
he thought the only chance of saving the patient. — Land. Bled. Gaz., Sept. 1848. 

50. Treatment of Hemorrhage after Excision of the Tonsil. — M. Hatin having met 
with a case of most alarming hemorrhage after the excision of a hypertrophied 
tonsil, which resisted all the usual styptics, an ingenious and successful mode of 
employing compression occurred to him. He took a long straight pair of forceps, 
used for the removal of polypi from the posterior nares, and having covered one 
of the blades with amadou and lint, applied it to the bleeding part, applying the 
other blade externally to the angle of the jaw, any amount of compression being 
producible by approximating the handles. M. Malgaigne, to whom the account 
of the case was sent, refers to a discussion which took place upon the same sub- 
ject at the Surgical Society. In the case which gave rise to it, M. Chassaignac 
succeeded, after everything else had failed, in arresting the bleeding by holding 
a piece of ice by means of a forceps in constant proximity to the bleeding point. 
M. Guersent had met with three cases, one in the adult, stopped by the actual 
cautery; one of the two children had a hemorrhagic tendency, and in the other 
an alarming hemorrhage occurred on the third day. Muriatic acid and honey 
succeeded best, ferruginous preparations being given internally. In the only case 
met with by M. Huguier, he found ice-drinks suffice. M. Robert doubted the 
propriety of using ice in these cases, as it has sometimes produced a gangrenous 
eschar. He recommends that the thumb dipped in alum should be applied to 
the bleeding point, making corresponding pressure with the fingers externally. 
M. Monod was acquainted with cases in which the mere keeping the mouth open 
sufficed to restrain the hemorrhage. M. Malgaigne observes that he has never 
known hemorrhage follow either excision of the tonsil or of the uvula. Lisfranc, 
however, met with a bad case of the latter, and arrested the bleeding by com- 
pressing the part with a forceps, and applying nitrate of silver to the wound. M. 
Malgaigne has met with two cases of traumatic bleeding from the fauces. In the 
one, it succeeded the removal of a tumour, and was arrested by the application of 
the finger for a few minutes. In the other case it followed the division of an 
anormal adhesion of the velum palati, which completely obstructed the nasal 
fossae ; and the bleeding was only controlled as long as pressure was kept up. 
Believing that the obstruction of respiration contributed much to the continuance 
of the hemorrhage, M. Malgaigne rapidly completed the operation, and the 
passage of air being now free through the nares, the bleeding stopped as if by 
enchantment. Brit, For. Med.-Chir. Rev., Oct. 1848, from Rev. Med.-Chir., vol. ii. 

51. Gun-shot Wounds. — After the fatal struggles of February and June of last 
year, the Parisian Hospitals presented rare opportunities for the observation of 
gun-shot wounds, .under very favourable circumstances for their study; and the 
occasion seems to have been zealously embraced by the able surgeons of Paris 
to examine the truth of certain opinions and the value of certain modes of prac- 
tice, respecting which diversity of opinion exists. Dr. Waters, in an interesting 
paper in our valued cotemporary, the Monthly Journal and Retrospect of the Medical 
Sciences, has given a good summary of these investigations, and we shall adopt his 
sketches in the following articles: 



196 



Progress of the Medical Sciences. 



[Jan. 



52. Character of the Orifices of Gun-shot Wounds. — The profession generally, guided 
chiefly by the opinions of military surgeons, till within a recent period, adopted 
the belief, that the orifice of entry of a musket or pistol ball was, in all but excep- 
tional cases, distinguishable from that of exit; that the former presented a clean 
equal border, somewhat depressed, and more or less contused; the latter a more 
or less irregular one, projecting outwards, and evincing less contusion ; further, 
the exit of the ball was supposed to be marked by a larger orifice than its entrance. 

M. Nelaton agrees in opinion with the military surgeons; but insists on the dif- 
ferent appearances which the orifices present, according to the period at which 
they are examined. 

When the wound is recent the orifices offer notable differences; that of entry 
is depressed, ecchymosed, contused ; that of exit is somewhat prominent and lace- 
rated; — the former presents a loss of substance ; the second a simple solution of 
continuity, the flaps of which, if brought together, would almost completely close 
the wound : the irregularity of the flaps and borders renders the latter orifice the 
larger, notwithstanding the absence of the loss of substance. 

After the lapse of some days the case is different ; the eschar becomes detached 
from the orifice of entry, which is thus proportionately enlarged ; on the contrary, 
the flaps, bordering that of exit, become partially united, and this orifice is dimin- 
ished accordingly. 

In a medico-legal light these distinctions possess great weight; recent observa- 
tions materially diminish their value. There can be no doubt that, where all the 
distinctive signs enumerated exist, their testimony is conclusive; but unfortunately 
it is found that, in a very considerable proportion of cases, some of the signs are 
absent, and under such circumstances there is abundant evidence to prove, that 
frequently no positive deduction can be drawn from those present. 

Different from what occurs in general engagements, the combatants in the streets 
of Paris often saw the hand that struck them, and were thus enabled to state posi- 
tively the point of entrance of the ball. On these data, tested by all the circum- 
stances throwing light on the inquiry, such as a knowledge of the position of the 
patient at the time of being wounded, the direction of the wound, &c, it is clearly 
established that, in numerous instances, the orifice of entry exceeded in size that 
of exit, and that its form was more irregular. M. Ronx stated before the Academy, 
that, in his cases, he observed about an equal number of variations on the one 
side as the other; an observation which may be extended to the practice of other 
surgeons. In a case of a gun-shot wound of the thigh with only one orifice, in 
the service of M. Boyer, the ball had traversed the muscular parts transversely at 
the upper third, and remained lodged beneath the skin on the side opposed to that 
where it penetrated. The ball, extracted by incision, was perfectly round, not- 
withstanding which the orifice, that necessarily of entry, presented an irregular 
border. In other instances, in the same service, where the limb was completely 
traversed, not the slightest difference in character between the two openings could 
be detected on the most careful examination directed specially to that end. 

M. Blandin appears to have been the first to question the correctness of the rule 
thus impugned : his experience in gun-shot wounds has long convinced him that 
the aperture of entrance is. in all but exceptional cases, the larger, and experi- 
ments performed by him are said to have proved the accuracy of his observation. 
According to him, the ball, where it strikes the skin, being supported by pans 
more or less resistant, acts as a punch, and produces an aperture nearly equal to 
its diameter; at its point of exit, on the contrary, the skin gives way before it, 
stretches in virtue of its elasticity, and is only traversed when it has attained its 
utmost degree of extensibility : the loss of substance is thus rendered very trifling, 
and the aperture consequently smaller than that of entry. M. Gerdy maintains 
the same opinion; and in this case also it is founded not merely on the examina- 
tion of the wounded, but on numerous experiments performed on the dead sub- 
ject and on living animals: in some of these the two orifices were precisely simi- 
lar. It may be objected that results obtained on the dead body and inferior animals 
cannot be considered an exact criterion of what occurs in man during life ; it is 
difficult, however, to conceive experiments belter devised to solve the question, 
and, when conjoined with the facts observed in the Parisian hospitals, they con- 
stitute a body of evidence which seems to place it beyond doubly that, in a greas 



1849.] 



Surgery. 



197 



number of instances, the orifices do not afford conclusive characters by which that 
of entrance may be distinguished from that of exit. 

No satisfactory explanation of these conflicting facts has been advanced ; but it 
is not improbable that the distance at which the wound is inflicted may affect its 
appearance. Thus when the shot is fired at a short distance, the wadding, being 
carried along with the ball, may render the orifice of entry larger and more irre- 
gular than that of exit, in consequence of the wadding having been deposited in 
its passage through the soft parts; when the shot is fired at a greater distance, the 
absence of the wadding may render the two orifices nearly or exactly alike; if 
the ball in its passage come in contact with a solid substance, such as bone, its 
form may be altered, and its exit give rise to a jagged opening w 7 ith projecting 
borders. 

When a ball is nearly spent, as shown by the distance to which it penetrates, 
where there is only one opening, this not unfrequently resembles a simple inci- 
sion, a circumstance observed in some cases. That the point of exit should occa- 
sionally present a similar character is therefore easily explained. 

53. Dilatation of G an- shot Wounds unconnected with Fracture. — The practice of di- 
lating the orifices and canals of all gun-shot wounds once prevailed. John Hunter 
was among the first to oppose this useless and injurious proceeding, and the force 
of his judgment and reasoning speedily showed itself in the general adoption of 
his views by British surgeons. Foreigners of eminence, amongst whom Larrey 
pere, and Sanson may be mentioned, followed in the same track; still, long after 
the abandonment of the practice amongst us, it continued to be inculcated on the 
continent, where the influential example of Dupuytren contributed powerfully to 
postpone the period of its rejection. 

The confidence of the profession in its utility is now so completely overthrown, 
that any recapitulation of the objections to the proceeding is unnecessary. M. 
Baudens, the celebrated surgeon-in-cbief of the military hospital of Val-de-Grace, 
declares the threatened tension, to obviate which the scarification was practiced, 
to be exceedingly rare where the ball has traversed soft parts without producing 
fracture, and stigmatizes it as a scarecrow ; his testimony is the more valuable as 
he once entertained a contrary opinion. Imbued with the doctrines imbibed dur- 
ing studies in Paris, and acting under the dictates of what he considered to be an 
imperative duty, he, on his first arrival in Africa, dilated ail the wounds, though 
not without feeling acutely for the sufferings he inflicted. While acting thus, a 
voltigeur, with the two thighs traversed by a ball at their superior third, without 
fracture, was brought to him. To effect dilatation large and deep incisions of the 
four wounds were requisite. His courage failed him; cold water dressings were 
applied; and, while dreading the consequences of his conduct, the cure progressed 
steadily and rapidly.* From that moment he abandoned the practice, and the 
propriety of his having done so will not at the present day be disputed. Several 
cases are recorded where flesh wounds treated on this principle have been ob- 
served to heal by the first intention ; when this happens, it seems certain that the 
contusion, ordinarily produced by the passage of the projectile, cannot exist. It 
has been attempted to explain the occurrence by supposing, that in these exam- 
ples the projectile had acquired an angular form, and consequently acted as a 
cutting, and not as a contusing body. A more simple explanation is based on the 
fact already recorded, that, when the force of the ball is nearly exhausted, its con- 
tusing power is lost, and it produces, notwithstanding its spherical form, a simple 
incision. This view derives corroboration from the circumstance, that the orifice 
of exit and the portion of the wound near it have been seen to heal by the first 
intention, while the remaining portion passed through the slower process of sepa- 
ration of a slough, suppuration, and granulation. 

M. Velpeau denies that gun-shot wounds can heal without the separation of an 
eschar. He asserts that all the tissues touched by the ball are disorganized, and 
must be thrown off, and that the premature closure of the external orifices, by im- 

* The conversion of M. Baudens, which shows to how late a period this practice was 
advocated in the surgical school of Paris, is recorded by Sir George Baliin gall in his 
"Outlines of Military Surgery," 2d ed. p. 216. 



198 



Progress of the Medical Sciences, 



[Jan. 



prisoning the putrid detritus, becomes a source of great danger. Of the applica- 
bility of this reasoning to the immense majority of cases, there can be no doubt; 
but the value of those of an opposite bearing is not on that account in any degree 
affected, and indisputable facts are mentioned by Larrey, Sir George Ballingall, 
Sanson, and others, where the cure was completed without any separation of 
eschar. 

The utility of the rejection of scarification is not limited to the condition already 
detailed. It has been extended with the best results to cases where important 
articulations have been traversed. The following occurred in the service of M. 
Jobert at St. Louis : — 

" Salle St. Augustin, No. 68. — Delevie, soldier, aged twenty-five, of good con- 
stitution and sober habits, wounded June 23, 1848. He was struck by a ball in 
the popliteal space between the heads of the gastrocnemius muscle ; it traversed 
the articulation of the knee-joint and emerged in front, having passed through the 
patella at its inferior portion without fracturing it. The wound did not occasion 
any marked general disturbance ; no examination by probe or otherwise was made 
in the tract of the ball ; the knee was kept perfectly at rest, and dressed with cold 
linseed meal poultices, frequently changed during the day and night; horizontal 
position on a pillow ; no splint. Slight effusion took place in the articulation ; but 
the inflammatory symptoms were exceedingly moderate, and speedily got under. 
The patient suffered no pain ; the orifices of the wound gave no evidence of sup- 
puration, and on the 25th of July cicatrization was complete; there was no swell- 
ing of the joint, and he was allowed to move about with the assistance of crutches. 
The movements of the limb were preserved : extension of the leg was performed 
without difficulty, but flexion occasioned some uneasiness." 

M. Jobert is of opinion that some slight adhesions exist within the joint, occa- 
sioned by the development of false membranes. In the wards of the same sur- 
geon, two other cases exist in which the articulation of the knee-joint was tra- 
versed, where the same treatment has been equally successful. An analogous 
one is said to be seen in the service of M. Gosselin. A similar case happened 
in the practice of M. Vidal de Cassis, and is related in his work on " External 
Pathology." 

11 A soldier, w r ounded in July, 1830, had the articulation of the knee traversed 
by a ball, which entered in front above the patella and emerged posteriorly, im- 
mediately below the popliteal space. In consultation with M. Guersant jils, he 
decided on not dilatating the wound, and the patient was perfectly cured. There 
was neither local nor general disturbance; the patient affirmed that he suffered 
nothing from the wound, the progress lo cure of which was remarkably simple. 
The suppuration was so trifling, that without the attention bestowed on the wound, 
it might have been considered to have healed by the first intention." 

It seldom happens that balls traverse articulations without serious injury to the 
articular surfaces; and examples of such success are. therefore, necessarily rare. 
M. Vidal de Cassis was not acquainted with one at the time at which he wrote. 
In two instances of wound of the same joint in the service of M. Jobert, the result 
was not so fortunate ; and in the wards of M. Velpeau there are also two exam- 
ples where the suppuration is very abundant. The fortunate termination in the 
cases that have been mentioned is not the less to be attributed to the treatment; 
and the good effects of non-interference with cutting or other instruments, are thus 
strikingly exemplified, and afford every encouragement for the adoption of the 
same course under the like circumstances. Dilatation of a wound of a synovial 
membrane is at least as formidable as amputation. 

Where, therefore, a ball has traversed an articulation without material injury to 
the bones, — injury of which would be betrayed not only by local, but also by sym- 
pathetic constitutional disturbance, — no exploratory attempts should be made, but 
the strictest repose enjoined, and appropriate treatment adopted, in order to ward 
off or diminish inflammation. 

54. Balls lodged in the Bones. Hopital St. Louis, service of M. Jobert. Salle St. 
Augustin, No. 7. — Boy. aged sixteen, wounded June 23, was struck by a musket- 
ball near the inferior third of the right leg anteriorly: the ball buried itself in the 
body of the tibia, without otherwise fracturing the bone ; no attempt at extraction 



1849.] 



Surgery. 



199 



was made; the ball remained in the bone; the external wound marched steadily 
towards cure; on the 25th of July cicatrization was complete, and a day or two 
subsequently the patient left the hospital. The integuments covering the tibia 
anteriorly in its superior half presented extensive cicatrices, the result of necrosis 
of a considerable portion of the bone, caused by the fall of a piece of iron on his 
leg. This was followed by a long suppuration, and the extraction of considerable 
fragments. .The patient had recovered from the effects of this accident previous 
to the infliction of the present wound, which occupied a portion of bone exempt 
from and inferior to that previously implicated. 

Some rare cases have been observed where balls have 'remained lodged in 
bones without causing any disturbance; a preparation exists in the Musee Dupuy- 
tren, in which a musket-ball is encysted in the substance of the tibia. The sub- 
ject from whom it was taken was a French soldier, wounded in 1814. Percy 
mentions the case of an old carabineer who carried a ball in the tibia up to the 
time of his death, a period of twenty-five years; a few others are on record, but 
their small number constitutes a prima facie argument in favour of the condition, 
that balls cannot occupy such a position without causing symptoms which demand 
their removal; numerous cases are related where, after a shorter or longer period, 
their extraction was thus necessitated. 

M. Jobert maintains a contrary opinion, influenced by the observations of balls 
lodged with impunity in the bones of animals, the hippopotamus, elephant, stag, 
&c. ; he maintains that the same may equally take place in the human frame, and 
consequently condemns their extraction, as causing unnecessary torment and re- 
tarding the cure, unless when they are superficially situated, and can be removed 
without difficulty. In this he is opposed to nearly all surgeons. M. Baudens 
unites with others in insisting on their extraction, and, where the forceps is una- 
vailing, prescribes the application of the trephine. Dupuytren directs their ex- 
traction when practicable, as it is only very rarely that they do not occasion grave 
accidents; caries and necrosis almost always follow. Guthrie establishes the 
same principle; according to him, their presence in the extremities of bones gives 
rise to caries — in the body of long bones and in flat bones, to necrosis. 

The practice of M. Jobert in these circumstances, is based on so small a num- 
ber of facts that it stands little chance of being adopted. Arguments, founded on 
what is observed in animals, are admitted to have but a very limited application 
to man; for, were it otherwise, ligature of the aorta would be proved to be a prac- 
ticable operation. Blandin once failed in killing a sheep, though he opened the 
arterial trunks of all the extremities and the neck. 

55. Treatment of Fractures of the Extremities in connection with Gun-shot Wounds. — 
Two distinctly opposite methods are pursued in the treatment of fractures caused 
by gun-shot wounds, and these extremes are connected by the practice of those 
who follow a middle course. An examination of the results and merits of these 
different methods will now be entered on. 

In order to facilitate the consideration of the subject, these fractures will be di- 
vided into, first — simple, the term being used not in the ordinary surgical sense, 
but as indicating that the bone has been fractured without the detachment of frag- 
ments; and, secondly — comminuted, where this complication exists. 

The second class is that in which the difference of treatment is most striking, and 
will be first treated. It offers several points for examination. These are : — a. — 
Dilatation and extraction of splinters, b. — Dressing and apparatus, e. — Cases 
demanding amputation, d. — Cases demanding resection. These questions will be 
discussed separately. 

a. — Dilatation and Extraction of Splinters. 

The various circumstances under which the splinters of bone characterizing the 
second class of cases present themselves, modify the treatment, and a division of 
them which indicates these circumstances is therefore indispensable; that of Du- 
puytren answers every purpose, and will be here followed. According to him, 
the fragments are of three kinds, namely, — primary, secondary, and tertiary. 

Primary fragments are those which are entirely separated from the bone and 
soft parts during the infliction of the wound. 



200 



Progress of the Medical Sciences, 



[Jan. 



Secondary fragments are those which are not completely detached from the 
bones and soft parts, being still connected to the latter by portions of tendon, mus- 
cle, ligament, &c. 

Tertiary fragments, those, namely, which result from the contusion of the bones 
by the projectiles in the portions which border the point of fracture, and which 
nature produces in virtue of a particular process, ordinarily exceedingly long in 
cornpleiion, and lasting sometimes ten, fifteen, or twenty years. Dupu>tren re- 
lates the case of a soldier wounded in 1813, and admitted into the Hotel Dieu in 
1830, in consequence of tertiary fragments following a gun-shot wound received 
at that period. 

Among the surgeons of Paris, MM. Jobert and Baudens respectively occupy 
the extremes of the scale referred to as marking the treatment of these injuries, 
and are distinguished by the zeal with which they support their opinions. 

In all gun-shot wounds M. Jobert adopts a uniform and exclusive mode of prac- 
tice; he deprecates all interference with the wound in every instance, even in 
cases of comminuted fracture. He not ordy condemns the extraction of splinters 
of whatever kind, and leaves their discharge entirely to nature, but interdicts for- 
mally all examination of the wound. He combats local inflammatory symptoms 
by antiphlogistic measures, and, when the tension becomes excessive, relieves it 
by two longitudinal incisions, from three to five inches long, and penetrating 
through the skin and cellular tissue, practised on each side of the orifices at a dis- 
tance of about two inches;* he invariably avoids dilatation of the wound itself. 
He justifies this treatment by the advantage obtained in preventing the access of 
air to the fracture, with which that obtained from the extraction of the fragments 
cannot, he contends, be compared. He further maintains, that direct benefit is 
obtained from the presence of the fragments — from those even that are completely 
detached — in that they contribute to the consolidation of the fracture, and prevent 
the formation of false joints; and he believes that in many instances useful limbs 
may thus be saved which would otherwise be sacrificed. The patient, it is ad- 
mitted, may occasionally suffer for a time from the presence of the necrosed por- 
tions; but these are gradually eliminated, and the limb ultimately regains its 
original power. In other instances, hi accordance with his views in respect to 
the lodgment of balls in bones, he maintains that the necrosed portions may oc- 
cupy the callus, and remain for an indefinite period without giving rise to any 
annoyance. To support the correctness of these views he adduces the following 
cases: — in one of these the patient was wounded in February. The humerus was 
fractured comminutively near its head; the ball passed out; no dilatation nor ex- 
traction of fragments was practised, but some portions of bone were removed dur- 
ing the suppuration. An enormous mass of callus is developed around the seat 
of fracture, and consolidation has taken place. The callus incloses portions of 
dead bone, and a fistulous opening on the outer surface of the arm communicates 
with the seat of fracture. The patient retains the use of his hand, but is unable to 
raise or support the weight of his arm, which he carries in a sling ; he suffers but 
little, and his health is good. The remaining patient had the humerus fractured 
by a musket-ball at the upper third, during the days of June; no examination of 
the wound nor extraction of fragments was practised. Consolidation of the 
fracture is now complete, and the wound perfectly healed. The only deformity 
of the arm is occasioned by the exuberance of the provisional callus, which is be- 
lieved to contain necrosed portions of bone. The patient continues to support his 
arm in a sling. 

M. Jobert attaches great importance to these cases, regards the results as among 
the finest ever obtained in surgery, and as fully justilying him in not extracting 
fragments of any description. 

M. Baudens pursues an entirely opposite treatment. In all cases of fracture 
caused by sun-shot wounds, his first care is to ascertain the nature of the parts by 
direct examination; and if the existence of splinters be established, and there be 

* When a wound heals with difficulty, in consequence of the ablation of a considera* 
ble portion of the skin, M. Jobert adopts the same practice. In a case recently in his 
wards, where the breast had been removed on account of a tumour, these incisions were 
practised with excellent effect. 



1849.] 



Surgery. 



201 



any hope of saving a useful limb, he immediately places the patient under the in- 
fluence of chloroform, practises the necessary dilatation, and extracts all the frag- 
ments of bone, whether primary or secondary ; his object in this being to convert, 
as nearly as may be, these formidable wounds into simple ones. 

The first authorities, among whom Dupuytren may be cited, have always 
ascribed the local accidents attendant on these fractures to the presence of the 
splinters, which, acting as foreign bodies, light up and aggravate inflammation. 
In several cases M. Baudens, guided by the character of the local symptoms, the 
tension and discoloration of the skin, inflammation in short putting on a phleg- 
monous appearance, assumed the presence of splinters, and confirmed his diag- 
nosis by forthwith administering chloroform to the patient and extracting them ; 
in such cases he then, with a razor, practised long superficial incisions, not em- 
bracing the whole thickness of the skin, in order to relieve the engorgement, and 
applied ice to diminish the action. 

It is thus shown that M. Baudens extracts all foreign substances, and that he 
not only removes the primitive or detached fragments, but also the secondary, or 
those still connected with the soft parts. Till lately no difference of opinion ex- 
isted as to the propriety of this practice in the first class; but with regard to the 
second the case was different. Dupuytren, who advocated the immediate re- 
moval of the first, inculcated in his lectures, that in the greater number of cases 
the second were not to be extracted, unless when the operation could be per- 
formed without danger of hemorrhage or severe pain, and then only when the 
fragments had been more or less detached by suppuration ; that is to say, at the 
termination of a variable period, eight, ten, fifteen, twenty days, a month, or even 
later. M. Baudens removes them at once, and his long experience in Africa gives 
great weight to his opinions. 

Two objections only are urged by Dupuytren against the latter mode of pro- 
ceeding ; one is the severity of the pain attendant on the operation, and he has 
recorded a case where he was forced to desist from researches which he had com- 
menced, owing to the sufferings of the patient. The anaesthetic properties of chlo- 
roform completely overrule this objection ; it is only necessary to witness its em- 
ployment in these cases, to acknowledge unhesitatingly its beneficial effects. 

The remaining objection, that, namely, of the danger of hemorrhage, alone 
therefore demands consideration. This danger, as resulting from the extraction 
of the splinters, seems to be more apparent than real. In reference exclusively 
to fractures of the extremities, it is difficult to conceive any grounds for dread in 
this respect, where amputation would not be directly indicated ; where it required, 
however, to proceed to their extraction in comminuted fractures of the thigh, the 
depth of the parts might seriously complicate and impede the operation. On the 
other hand, cases exist where the presence of the fragments seems to have been 
the cause of hemorrhage. 

Case fifty-three, in the work of Dupuytren, supports this conclusion ; it occurred 
in July, 1830. A ball fractured the two bones of the leg at the superior third ; an 
attempt to preserve the limb was determined on. The orifices of exit and entry 
were dilated, the limb fixed in a fracture apparatus, with the looped bandage, and 
laid on pillows. Every thing went on well; the fever was moderate; the patient 
suffered little, and a healthy suppuration established itself, which daily became 
more abundant. The general condition of the patient continued pretty good ; no 
rigors, no diarrhoea, no colliquative sweating, no pain in any region of the body. 
Such was the condition the 16th day after the accident, when, after a dressing per- 
formed with the greatest gentleness and precaution, a violent hemorrhage of a 
bright red colour manifested itself, and amputation of the thigh was performed. 

Examination of the amputated leg. — The tibia and fibula were fractured commi- 
nutively at their superior fourth ; fifteen or twenty fragments belonging to one and 
the other of these bones, and almost all detached, occupied the seat of fracture ; 
the soft parts were torn, destroyed, and reduced to a pulp; purulent collections ex- 
isted between the different muscular layers; the anterior tibial artery was altered 
by putrefaction, and presented an opening at its passage through the interosseous 
ligament. 

This is a most instructive case ; the condition of the parts at the time of ampu- 
tation, showed how delusive were the hopes of success which had been enter- 



202 



Progress of the Medical Sciences. 



[Jan. 



tained during the treatment. The artery was either opened directly by the action 
of a splinter on its altered coats, or by ulceration resulting from the inflammation 
entertained by the fragments of bone. 

Ligature of the femoral was agitated and rejected. The advocates of M. Jobert's 
treatment may attribute the unfavourable result to the dilatation of the orifices, 
permitting the admission of air to the seat of fracture; in the following case this 
practice was not adopted, and yet the result was equally unfortunate. 

One of the wounded of June was admitted into the Hospital of St. Louis, under 
the care of M. Malgaigne, with comminuted fracture of the humerus at its upper 
fourth, from a musket-ball. No dilatation nor extraction of splinters was attempted ; 
there were two orifices. July 10th, considerable hemorrhage manifested itself, 
which was arrested temporarily by compression; it recurred again and again, and 
the following morning disarticulation at the shoulder joint was performed. The 
patient was in a weak blanched state; the operation was executed while in bed ; 
chloroform was administered; a very trifling amount of blood was lost, but death 
supervened during the operation; the union of the flaps was in consequence not 
effected. 

Three other cases of secondary hemorrhage have occurred in the practice of 
this surgeon, where no examination of the wound had been performed, and all 
terminated fatally. 

The necessity of examining the wound in these fractures was forcibly exempli- 
fied by its condition in the present instance; numerous detached fragments occu- 
pied the seat of fracture, the surrounding soft parts presented a disorganized, dark, 
pulpy appearance. A portion of the ball, much disfigured, was extracted from 
under the pectoralis major muscle. 

M. Pelletan has recorded a case of hemorrhage on the 70th day, occasioned by 
the presence of a splinter. 

These cases might easily be multiplied, but a sufficient number has been ad- 
vanced to show that the occurrence of hemorrhage may with equal reason be 
urged against allowing the fragments to remain, as against proceeding to their ex- 
traction. Any dread from this cause cannot be considered sufficient to deter the^ 
educated surgeon of the present day from a beneficial operation. 

It may be argued that the secondary splinters, retaining connection with the 
soft parts, and consequently not completely cut off from the circulation are not 
incapable of preserving their vitality, and on that account should not be removed. 
Experience does not confirm such a conclusion ; the inflammation which they ex- 
cite speedily isolates them; the pus resulting from a chronic abscess may long rest 
with impunity in contact with the periosteum, but that accompanying active in- 
flammation rapidly destroys it, the nutrition of the fragment ceases, and it becomes 
converted into a true foreign body. When comminuted fracture of the bone has 
occurred without breach of the tegumentary surface, where a cutting instrument 
has effected a separation of a portion of bone without destroying its connection 
with the soft parts, where a compound fracture has resulted from an accident 
which has exerted no contusing power directly on the bone, we know that reunion 
of the fragments may take place. In comminuted fractures from gun-shot wounds, 
the condition of the parts is in no way the same; the projectile exerts on the bones 
an action analogous to that observed on the soft parts; the contusion caused by the 
projectile adds to the disturbance occasioned by the fragments, and a high degree 
of inflammation is inevitably excited, which rapidly destroys their connection 
with the living organism ; the slate of the parts in these fractures differs, there- 
fore, from that existing in those produced by other means. 

Experience fully convinced Dupuytren of the futility of expecting that the 
secondary fragments would retain their vitality; he asserts that their detachment 
is operated spontaneously, through suppuration at a shorter or longer period, vary- 
ing from eight days to even months. During this period they keep up a con- 
stant irritation, and aggravate the local symptoms; the general disturbance is known 
to be always in proportion to that of the local inflammatory accidents; moderate 
when these are calmed by judicious measures, but, on the contrary, of a formida- 
ble character when these are neglected, or badly treated, or treated ineffectually. 

It is to obviate these inconveniences that Baudens and Nelaton advise the re- 
moval of these fragments, as well as the primary ones ; in order to place the pa- 



1849.] 



Surgery. 



203 



tient at once in a condition, which is otherwise only attained at the expiration of 
an indefinite period. — the period necessary for their spontaneous removal. The 
patient is thus in the best possible position for ultimate cure; the chief cause of 
local inflammation is removed; the general fever diminishes proportionally; the 
strength is not worn down by prolonged suffering and suppuration, nor the nervous 
irritability of the patient morbidly increased. Twenty-five cases in the wards of 
M. Baudens, in which he followed these rules, and which are all terminating fa- 
vourably, attest the efficacy of the practice. 

Another argument in favour of this practice may be drawn from the occurrence 
of tertiary fragments, as whatever tends to heighten the local inflammation favours 
their formation. M. Baudens proceeds to the extraction of these as soon as their 
existence is ascertained, and the operation practicable. 

The question now presents itself, whether the success of M. Jobert, and those 
who side with him, is such as to overrule the treatment here approved. Statistics 
are not yet attainable, and it is probably by these that the question will ultimately 
be judged. The practice of M. Jobert already offers two successful cases, so called ; 
in these, consolidation of the fracture has certainly taken place, but an enormous 
mass of provisional callus is formed, inclosing several necrosed portions of bone; 
these represent true sequestra, will necessarily play the part of foreign bodies, and 
probably, at a future period, become the cause of great suffering. In the mean 
time, the progress of the healing process within the provisional callus is unknown, 
and a considerable time must elapse before it can be ascertained. In the man 
wounded in February a fistulous opening exists, as already stated, in communi- 
cation with the seat of fracture. M. Jobert believes that portions of necrosed bone 
may, like balls, remain in the bones without injurious consequences; according 
to Dupuytren their sojourn in the midst of callus is one of the most common 
causes of deformity, and of interminable fistula. In certain cases no provisional 
callus forms, and it is only after the separation of the necrosed portions that con- 
solidation takes place. 

M. Malgaigne adopts the expectant mode of treatment at first ; but when sup- 
puration is established, makes frequent use of the probe and forceps, extracting 
splinters six and seven weeks after the infliction of the wound. In a case of com- 
minuted fracture of the forearm, no examination of the fracture was made on ad- 
mission; fifteen days afterwards, splinters began to come away by the suppurative 
process: as late as eight weeks after the infliction of the wound, he dilated one 
of the orifices to facilitate the extraction of a splinter. 

Other surgeons extracted immediately the most easily reached primary frag- 
ments, and renewed the examination of the wound, day after day, to extract those 
remaining, and the secondary as they became loosened; at each examination 
causing much suffering to the patient. 

The foregoing facts and reflections are held to indicate, that in every case of 
comminuted fracture of the extremities, where an attempt is made to save the 
limb, extraction of all the splinters of bone is imperatively demanded. 

56. Operations for excising parts of the Hip-joint in Scrofulous Caries of the Articula- 
tion. — [The following remarks by Mr. H B. Norman, on these operations, appear 
to us judicious and worthy of consideration:] 

The attention of the readers of the Lancet has been drawn of late, by Mr. 
Henry Smith, to the revival of operations for removing parts of the upper end 
and head of the femur in certain cases of disease of the hip-joint. There is no 
great difficulty in the performance of these operations to any one accustomed to 
surgical manipulations, nor danger of injuring important vessels or nerves; and 
I would not be considered as opposed to their fair trial in well-selected cases. At 
this moment indeed I am watching, with much interest, a case, in which I con- 
template operating.' But there are circumstances in the present day, and in the 
existing state of our profession, which make great caution needful, lest we be 
hurried away too rapidly afier novelties or revived antiquities, and be led to act, as 
seeking our own interest and renown, with more zeal than for the welfare of our 
patients. In surgery such caution is much needed, and before we undertake any 
proposed operative procedures, we are bound to consider seriously all reasonable 



204 



Progress of the Medical Sciences. 



[Jan. 



objections to them, and to weigh well such known circumstances as militate 
against them. If we think, further, that these circumstances are likely to be over- 
looked, we are bound to bring them forward. 

In respect to the operations now considered, the "constitutional character" of 
the disease proposed to be benefited demands especial notice In general, if not 
always, caries of the hip-joint is to ba regarded as a local manifestation of scro- 
fulous cachexia, excited, it may be, by local injury, but still only a symptom of a 
general disease. And the connection between this lesion, as well as the other 
local manifestations of scrofula, and tubercular deposits in the various internal 
organs, is well understood. The frequent coincidence of such visceral disease 
with that of the hip joint I regard as the most serious objection to the proposed 
operations. They have been performed, it appears, with some success of late in 
London ; and in the high respectability and reputation of the operators, Messrs. 
Fergusson, French, my friend Mr. Walton, &c, we have the best guarantee that 
due precaution was taken in the selection of the cases. My single object in these 
observations is to lead others to the same care, for all the objections which may 
exist to these or any other procedures may not occur to the minds of some san- 
guine of success and fame in being among the first to practise a novel, or rare 
and important operation. The diagnosis is all important and just, as it would af- 
ford but poor satisfaction to have amputated a thigh with the view of prolonging 
the life of a patient, who dies shortly after of an unsuspected aneurism; or to have 
extracted a cataract from an amaurotic eye ; so would it be disappointing and not 
to our credit, after having excised the head of the femur, and scooped away at a 
carious acetabulum, to see our patient dying of phthisis, overlooked or not sus- 
pected in deciding on the operation. Now as such misfortunes have happened, 
to the great dismay of surgeon, patient, and friends, possibly the greatest care 
and discrimination may not always suffice to protect us from them; but they must 
not be neglected nor forgotten. 

Another serious consideration is, the difficulty, nay, frequently the impossibility 
of forming even a rational opinion of the extent of the disease with which we 
have to cope. We may find, for instances, the disease limited to a superficial 
portion of the head of the femur, and of the surface of the acetabulum; or we 
may find the latter extensively diseased, even perforated, and communicating 
with large pelvic and lumbar abscess, or collections of curdy, scrofulous matter, 
analogous to softened tubercle. Not long since, I inspected, with my friend Dr. 
Hare, the body of a female who had died of Bright's disease, and who had a large 
fibrinous deposit in the liver, and had suffered also from disease of the hip. In 
this case the acetabulum was almost destroyed; a large hole existed in it, com- 
municating with an immense collection of curdy matter, which filled the iliac 
fossa and lumbar region of one side; the iliacus and psoas muscle were degene- 
rated, and completely infiltrated with the morbid product; sacro-iliac articulation 
was diseased also. — Lancet. July 8, 1848. 

57. Removal of a Carious Portion of a Rib. By Alexander Linoli. — Towards the 
end of 1845, a girl, three years of age, was attacked by pleurisy of the left side. 
After several weeks a tumour appeared beneath the left breast, and in proportion 
as it increased in size, there was an improvement in the respiration. An opening 
having been made into the tumour, a large quantity of sero-purulent matter was 
discharged; after two weeks this opening was permitted to close up, when another 
tumour appeared, and required to be treated in the same manner. Some time 
afterwards the cicatrix of the first wound opened, and continued to discharge puru- 
lent matter. Various attempts to cure it by means of caustic, &c, were made, but 
without success; when the patient having been brought to Dr. Linoli. he discovered 
numerous fistulous openings penetrating into the thoracic cavity, arising from caries 
of the sixth rib. In these circumstances, Dr. Linoli proposed the removal of the 
diseased bone. The operation was accordingly performed, and the edges of the 
wound having been carefully brought together, in five days were found to be united 
in almost their entire extent. In six weeks the «ure was quite completed, and the 
child's health re-established. — Montk. Retrospect, Dec. 1848, from Annali Univ. cli 
Med., March 1848. 



1849.] 



Surgery. 



205 



58. Fracture of the Head of the Humerus, and laceration of the Axillary Vein. — 
Mr. Fraser reports {Lancet, July 8th,) an example of this accident in a boy thirteen 
years of age, produced by a fall from a tree. Mr. F. threw two ligatures around 
the wounded vein, one -above, the other below the wound. Cold applications 
and appropriate dressings were applied, and the case terminated favourably. 

59. Ovariotomy — death. Mr. H. G. Potter reports in the Lancet (July 8th) a 
case of double ovarian disease in a female, thirty-six years of age, in which he 
operated by the large abdominal section, the patient being under the influence of 
chloroform. Death took place sixteen days afterwards. In his remarks on the case 
Mr. Potter observes : u Should ovariotomy ever be admitted within the pale of legi- 
timate surgery, it is evident that we must have the diagnostic signs of adhesions, 
and also the extent of such adhesions, more clearly defined than they are at pre- 
sent. Hitherto we have acted in the dark; and thus it has frequently happened, 
that where adhesions were least expected, there they have been found. In the 
above case, peritonitic symptoms might be almost said to be absent. The legs 
were never drawn up; she could rest equally well on back and side; the counte- 
nance did not assume the peritonitic aspect; and there was no tenderness (except 
at the wound) of the abdomen. The mucous membranes of the primes viae suf- 
fered severely, and the death of the patient seemed to be more immediately pro- 
duced by this affection than any other, though of course the operation was the 
primary cause. ;; 

60. Chloroform in Surgical Practice. — At a meeting of the Medico-Chirurgical 
Society of Edinburgh, Dr. Simpson asked Professor Miller and Dr. Duncan to 
state the extent to which they used chloroform in their public and private surgical 
practice. 

Professor Miller observed, that in the hospital and elsewhere the surgeons of 
Edinburgh had used chloroform in all their operations, with the exception, per- 
haps, of any such within the cavity of the mouth as were expected to be attended 
with much hemorrhage. And he could speak of its perfect success, and perfect 
certainty, and perfect safety, in the most unequivocal terms. There had been no 
misadventures, no failures, and now no fears of those spasms and other preliminary 
symptoms to which Dr. Simpson had alluded. In saying all this, he believed he 
was simply stating the opinion and experience of all his surgical brethren here; 
and that no one amongst them would deem himself justified, morally or profession- 
ally, in now cutting and operating upon a patient in a waking and sensitive 
state. Every professional principle, nay, the common principles of humanity, 
forbade it, seeing that sug^ery was now happily possessed of sure and safe means 
by which it could avoid the necessity of such cruelty. Those were strong opinions, 
strongly expressed, but, in answer to Dr. Simpson's question, it was impossible 
for him to say less. 

Dr. Duncan stated that he sincerely coincided in every part of the statement 
made by Professor Miller, and that, in his hospital and in his private practice, he 
constantly, like his other surgical brethren, used chloroform in all his operations, 
and even when making any painful examination for the purpose of diagnosis. 
There was only one case in which he had found a difficulty in its application, viz : 
when operating for internal hemorrhoids, the patient not, of course, having the 
capability of protruding the bowel when anaesthetic. 

Professor Miller sta-led that, in operating for internal hemorrhoids, he had latterly 
been in the habit of making the patient first protrude the bowel; he then fixed 
the hemorrhoid with a vulsellum, chloroformed the patient, and afterwards termi- 
nated the operation. — Month. Joum. Med. Science, July 1848. 

61. Local Anesthesia — M. Jules Roux recommends the application of liquid 
chloroform to the surface of a wound left after an operation, while the patient is 
still in a state of general anaesthesia, with the view of benumbing the cut ex- 
tremities of the nerves. The local insensibility is maintained, according to M. 
Roux, for forty-eight hours (?) and the patient is thus exempted from pain, both 
during and after the operation. 

A case of hydrocele is described, in which M. Roux injected four drachms of 
No. XXXIII.— Jan., 1849. 14 



206 



Progress of the Medical Sciences. 



[Jan. 



chloroform into the sac. Two drachms were allowed to remain. The case ran 
the ordinary course, a cure being obtained in fourteen days. — Gaz. des Hop., Nov. 
7, 1848. 

[A few days ago we applied liquid chloroform to an ulcer on the leg of a female, 
which required cauterization with the nitrate of silver. She appeared to suffer 
little pain from the chloroform, and certainly very much less than usual from the 
caustic. She refused to inhale the drug.] — Monthly Retros., Dec. 1848. 

62. Tetanus from Injury of the Ankle — Amputation — Repeated Etherization — Death. 
By M. Roux, Naval Surgeon in Chief of Cherbourg — 9th April, 1848. J. G., a 
robust man of nervous temperament, was admitted into the Hospital of Marine, 
at Cherbourg, suffering from fracture of the fibula, with complete dislocation, out- 
wards, of the ankle joint. There was a small wound over the inner malleolus. 
The foot was easily replaced. Next morning there was neither swelling in the 
limb, nor general fever. 

On the 12th, heat, redness, and swelling of the limb came on, accompanied by 
fever. During the next few days he became worse; fetid discharge came through 
the wound over the malleolus; and the parts over and within the articulation began 
to slough. 

Incisions were made, and on the 21st the swelling was lessened, but the general 
condition of the patient was worse : the foot was displaced ; the sloughing was 
extensive; the joint and the tibia exposed; the foot red and cedematous. In addi- 
tion, he spoke and swallowed with difficulty; and trismus was present. 

Amputation was now indispensable, and would have been already performed 
but for the general reaction, and the great swelling of the upper part of the leg. 
The immediate amputation of the limb was decided on, the occurrence of tetanus 
not being considered an obstacle. 

In five minutes unconsciousness was produced by chloroform. The inhalation 
was continued for three more minutes, until the stiffening of the limbs gave place 
to complete relaxation; and the leg was amputated, the patient being quite uncon- 
scious. The chloroformization was repeated several times during the operation; 
and the patient was insensible for about eighteen minutes. 

After the operation, the trismus was slightly lessened; but the jaws could only 
be partially opened. The patient complained of violent pain in the stump. In 
the course of the day chloroform was administered five times. Each time pain 
was suspended with consciousness, and the trismus lessened with muscular re- 
laxation. But these effects were only momentary. 

Next day the pain was lessened, but the trismus was more pronounced. Poul- 
tices, with laudanum, were applied to the wound. Etherization was practised six 
times in the course of the day. The effect of ether on the patient did not differ 
from that of chloroform. 

On the 23d, opisthotonos was established; but the limbs were still free, except 
during paroxysms. Ether was given once, and chloroform six times during the 
day. The ether excited a prolonged rigor, violent cough, and a sense of suffoca- 
tion. The ether was consequently exchanged for chloroform. During the evening, 
after the last inhalation, the bronchia? appeared to be filled with frothy fluid. 

On the 24th the symptoms were not materially modified. Deglutition w T as more 
laborious, and was always accompanied by cough and a sense of suffocation, as 
if each time liquid entered the air passages. The trismus and opisthotonos were 
complete and unyielding. He inhaled chloroform thrice during the day. The 
difficulty of breathing increased, and he became gradually worse. Deglutition 
was only possible during the short interval of muscular relaxation which followed 
the inhalation of chloroform. 

At midnight he became suddenly worse : the respiration being frequent and 
embarassed, the pulse rapid, and anxiety increased; convulsions came on; intelli- 
gence, hitherto scarcely affected, disappeared; a cold sweat covered the body; 
and, almost without asony, he died at 1 A. M., on the 25th. 

Autopsy twenty-four hours after death — Complete muscular relaxation, which came on 
a few hours after death. — The brain and spinal marrow, slightly congested, were in 
all respects normal. Little blood in the cavities of the heart. Lungs engorged, 



1849.] 



Ophthalmology. 



207 



but crepitating. Mucous membrane of the air passages, especially in the minute 
bronchi, of an ineffaceable red. Nothing remarkable was observed elsewhere. 

In this case, the anaesthetic inhalations were only followed by momentary relief. 
The etherism, sometimes exciting cough and sense of suffocation, aggravated, for 
the time, the disease. The progress of the disease was not modified by their use, 
since he died on the fifth day from the beginning of the attack; the usual period 
at which the tetanic die. 

In reflecting on the intense pain seated in the stump, it occurred to me, that 
direct etherization of the wounded surfaces might remove the painful impressions 
which were transmitted to the nervous centres, and cure the tetanus by removing 
the reflex action on the muscular system. It seemed to me that this local and 
direct etherization of the wounded surfaces would affect with anaesthesia the ex- 
tremities of the sensitive nerves; interrupt the connection of those nervous ex- 
tremities with their centres; deprive the nervous system of its painful participation 
in the suffering of divided parts: remove the muscles and the whole organism 
from the reaction which violent irritation in the incitor nerves produces: in a word, 
isolate the wound, by detaching it, so to speak, from animal life, without injuring 
its relations with organic life. This isolation, it appeared to me, might be obtained 
by the direct and continuous action on the wound of the vapours of chloroform or 
ether, without having to fear that the insensibility in the nerves would spread be- 
yond the points immediately acted on by the anaesthetic vapour, that there would 
be danger from absorption, or that the stump, deprived of the reaction of the whole 
economy, might want the necessary irritation to carry it through its successive 
stages to cicatrization : since these vapours, which deprive the nerves of their 
functions, excite the rest of the tissues. 

Experiments, with regard to the effect of local etherism on the lower animals 
and on man ; but these are neither sufficiently numerous nor decisive to be yet 
brought forward. — Lond. Med. Gaz., Sept. 1848. 



OPHTHALMOLOGY. 

63. Structure of the Vitreous Humour. — Dr. Hannover, of Copenhagen, has lately 
investigated this structure with great care, and his researches have controverted 
the generally received opinion of its being entirely a cell structure. The opinion 
of Pappenheim (who, having hardened the vitreous humour of an ox and a man, 
by treating it with carbonate of potash), that this body was composed of concen- 
tric layers, like those of an onion, is not quite correct, at least as far as the human 
eye is concerned, for this appearance is evidently the result of the coagulation of 
the albumen. M. Briicke, from whose observations Miiller took the description 
of the vitreous humour which he has published in his Physiology, used a concen- 
trated solution of the acetate of lead; but this physiologist's description is true only 
in part, as it does not define in what manner the different layers terminate. Dr. 
Hannover, who made his observations on the vitreous humours of several mam- 
miferous animals which had remained in a solution of chromic acid for at least 
six months, gives the following description of this substance. Its structure is 
clearest in the horse; if a transverse section of the eye be made horizontally, and 
passing through the optic nerve, a great number of concentric lamellae, which 
divide themselves into smaller ones, are observed; the external ones follow the 
internal circumference of the eye; they are thicker next to the retina, and thinner 
behind the crystalline lens. The vitreous humour, he says, considered as a whole, 
consists of several bags or cells, of various degrees of thickness, completely shut, 
and contained one within another. The exterior ones are naturally the largest, 
and the internal ones are nearer the entrance of the optic nerve than the lens. A 
line passing from the centre of the optic nerve, where it pierces the sclerotic, to 
the middle of the posterior surface of the lens, will pass through the summit of all 
these cells, and through the middle of their convexity. The exterior cells are 
softer and more transparent; the interior ones, especially those immediately behind 
the crystalline, are compact and thin ; all the cells are thicker towards the" sides of 
the eye, and become thin towards the optic nerve. If the eye is divided vertically, 



208 



Progress of the Medical Sciences. 



[Jan. 



the same onion-like structure of the laminae, particularly in the cat, dog, ox, and 
sheep, is observed. In man the vitreous humour is found to be chiefly composed 
of slices, the arches turned outward, and the angles converging towards the axis 
of the eye, somewhat like the segments of an orange, and this peculiarity is better 
observed in infants than adults. In two eyes which were very carefully examined 
by this observer, 180 rays were counted, but he has not been able to determine 
whether each segment has its own particular membrane, or a single membrane 
is common to two. Viewed with a microscope, the walls of the slices appear as 
simple transparent membranes, without any peculiar structure, but covered with 
innumerable small nuclei, which the author believes to be the result of precipita- 
tion. The axis, towards which all the slices converge, is the axis of the optic 
nerve. Having hardened a human eye in chromic acid, he made both horizontal 
and perpendicular sections of it. A horizontal section through the centre of the 
vitreous body presented a uniform plain surface, such as would result from the 
section of an orange cut right through the centre from pole to pole ; whereas a 
perpendicular section of the vitreous body corresponded with what would result 
from a section of an orange made at right angles with that last described, viz., a 
number of rays converging towards the centre, which rays correspond with the 
different divisions of the orange-like slices of which it is composed. — Dub. Quart. 
J own.. May, 1848, from Annates d' 'Oculwtique. 

64. Cholesterine Cataract. By W. R. Wilde, Esq. — About six years ago, a butcher, 
aged forty years, consulted us for loss of vision in his right eye, the result of a 
blow received some years previously. Upon examination we found a hard cata- 
ract, of a remarkable yellow colour, and to all appearance of a calcareous nature. 
Certain portions of its external surface presented the brilliant metallic appearance 
known as gold-leaf cataract. From its singularity we had an accurate drawing 
made of it at the time, and then lost sight of the patient for some years. Twelve 
months ago he again applied at the hospital, in great pain, and with the eye deeply 
inflamed, the result of a blow which he received upon the temple a few days pre- 
viously in a drunken squabble, when, to use his own expression, his eye was 
burst. Upon examination we found that, to a certain degree, his opinion was 
correct, concussion and dislocation of the lens having taken place. The central 
nucleus of the lens was lying at the bottom of the anterior chamber, and a quantity 
of brilliant matter, like broken-up gold leaf, floated through the aqueous fluid, and 
adhered to the back of the cornea. When the eye had been at rest for some time, 
the greater portion of these particles subsided to the bottom of the chamber, but 
upon moving the eye, or on the patient's making any exertion, they floated upward, 
producing the appearance which we sometimes see in the fundus of the eye, and 
which, under the name of " sparkling eye," has recently engaged the attention of 
oculists. We had an accurate drawing made of the eye in this condition. The 
usual antiphlogistic treatment having failed to afford relief, and the pain being 
most intolerable, we agreed to extract the lens, and remove as much of the offend- 
ing body as possible. As this very remarkable case afforded a rare opportunity 
for analyzing this peculiar form of cataract, Professor Aldridge carefully examined 
the case, and assisted us at the operation. We made an inferior section of the 
lower third of the cornea with Scott's extraction knife, which is well adapted for 
such cases, from the curvature on the back, and the little space which it occupies. 
During the incision a small eye-cup was held beneath the globe, in order to receive 
the lens, and other means adopted to preserve as much as possible of the substance 
we wished to analyze. As soon as the incision was completed, the great mass 
of the broken-up lens and the central nucleus immediately escaped, and the re- 
maining fragments were removed with Daviel's scoop. Immediate relief was 
experienced; the wound healed by the first intention, but with rather abroad cica- 
trix. There was no adhesion or distorsion of the pupil. The globe did not col- 
lapse, but the vision had been for many years extinct. 

We give the following account of the analysis from a letter of Professor 
Aldridge's : " You may recollect that, previous to operation, distinct and beautiful 
crystals were visible, attached to the interior of the cornea, similar to scales of 
yellow mica. These, during the operation, you scraped off, at my request, and 
handed them to me, together with the extracted lens. The crystals referred to, 



1849.] 



Ophthalmology. 



209 



when examined by the microscope, appeared under the form of rhombic plates. 
They were soluble in ether and hot alcohol, from the latter of which they recrys- 
tallized in cooling, and were insoluble in a solution of potash, which, however, 
removed their colour. The lens was anteriorly sprinkled closely with similar 
crystals, but when these were removed, by digesting with ether, the lens itself 
remained white and opaque. It was insoluble in water, alcohol, ether, or dilute 
acid, but -readily dissolved when gently heated in a solution of potash, and was 
again precipitable by acetic acid. I think there can be no doubt but that the crys- 
tals were chiefly composed of cholesterine, and that the cataract was due to the 
deposition of some proteine compound, and a distinct phenomenon from the crys- 
tallization of the cholesterine discovered upon its surface, and which was afterwards 
so manifest in the anterior chamber." Besides the general interest of this very 
curious case, there are two topics connected with it on which we would remark : 
First, — the value of having accurate drawings made of every remarkable case 
which occurs, even though at the moment no ultimate benefit, except that of re- 
presenting a peculiar form of disease, may appear to be gained ; and secondly. — 
the advantage which ophthalmic surgery must derive from the analysis of moibid 
products such as that described. — Dub. Quart. Journ., May, 1848. 

65. Sparkling Eye. By W. R. Wilde, Esq. — Tn synchysis and certain forms of 
ophthalmic disease we sometimes observe, upon looking steadily into the depth 
of the eye, that there is a peculiar scintillating appearance exhibited. At times 
this has the appearance of small sparks of light, not unlike the phosphorescence 
which sometimes appears upon the surface of the sea, particularly when the water 
is agitated. Those brilliant sparks generally appear to rise up from the inferior 
surface of the eye, and fall down again in a description of shower. In two cases 
which we have had under our care, this appearance could be induced by any 
motion or exertion, when it very much resembled the look which a bottle of eau 
de sie presents when the gold leaf in it is shaken up. There are other appearances 
in the eye of a luminous character, with which this must not be confounded. In 
certain forms of amaurosis we can, particularly when the pupil is dilated, perceive 
a brilliant yellow appearance, with a metallic lustre, and of a spherical shape, 
lining the fundus of the eye. At first view this might be taken for the early stage 
of malignant disease, but the history of the case, the age of the patient, and the 
attendant circumstances, will enable us to distinguish it from that affection, although, 
at times the differential diagnosis is exceedingly difficult. The scintillations to 
which we have alluded may or may not be attendant upon this form of disease. 
The cause of these appearances has lately engaged the attention of several conti- 
nental writers. M. Desmarres thinks that it is due to a peculiar morbid disposi- 
tion of the hyaloid cells, which, being less distended than natural, on account of 
the fluidity of the vitreous humour, and floating one over the other, reflect sepa- 
rately, instead of refracting the light. M. Malgaigne considers that this pheno- 
menon is owing to the presence of little foreign bodies floating in the vitreous 
humour, and put in motion during the movements of the eye. These he believes 
to be crystals of cholesterine, which reflect the light as they present themselves to 
it in several inclinations. M. Tavignot's opinion coincides with the latter. He 
says that he has collected some of these sparkling particles, and that they bore the 
greatest possible analogy to the corpuscules of cholestria sometimes found in the 
liquid of hydrocele. He does not know, he says, whether their chemical compo- 
sition be the same, but he considers it probable ; and he thinks that the crystalline 
capsule, from its serous character, at least upon one aspect, may give rise to a 
product similar to that produced by the tunica vaginalis.^ We incline to the opinion, 
that in a great many cases the sparkling appearances are caused by the chemical 
substance just alluded to ; and we are the more induced to believe this from the ex- 
amination of the gold-leaf cholesterine cataract already detailed : [see previous 
article;] but there are other cases where the brilliant appearances do not present 
a palpable character like those just described, but appear as brilliant, evanescent 
scintillations of light, even in the anterior chamber. — Ibid. 



* Revue Medico Chirurgicale, August, 1847. 



210 



Progress of the Medical Sciences. 



[Jan. 



66. Chloroform in the treatment of Ophthalmia. — M. Uytterhoeven has employed 
chloroform successfully in various forms of ophthalmia. In a patient at the Hopi- 
tal St. John, Brussels, he soothed by this means neuralgic pains resulting from 
injury of the eye. He has also found chloroform very useful in photophobia of 
scrofulous ophthalmia. M. U. prescribes it as a collyrium, in the dose of eight 
drops in an ounce of distilled water. 

MM. Busch and Cunier have administered it in the dose of from 8 to 16 drops 
in a mucilaginous potion of 60 grammes; to be taken in teaspoonful doses in the 
24 hours. The benefit obtained from it in eight cases of chronic scrofulous oph- 
thalmia, and in one of neuralgia of the eye ; was very remarkable. — Journal des 
Conn. Medico- Chirurg., Oct. 1848. 

67. Ergot of Rye a Remedy for Excessive Dilatation of the Pupil from Belladonna — 
M. Comperat has announced a plan by which he has succeeded in removing di- 
latation of the pupil produced by belladonna in a patient of his, in whom the iris 
was scarcely visible, so complete had been the action of a small dose of belladonna 
applied externally. For some days the excessive dilatation resisted the employ- 
ment of various collyria. He prescribed powdered ergot of rye, taken like snuff. 
The dilatation disappeared in a few seconds — it soon returned; the same remedy 
was again employed, and it did not reappear. He thought that ergot might be 
thus used in cases in which dilated pupil arises from the other causes. — Lond. 
Med. Gaz., Sept. 1848. 

68. Ergot of Rye in Mydriasis. By J. F. M'Evers, M. D., of Cork.— In the Lon- 
don Medical Gazette of September 8, a correspondent notices the peculiar action 
of ergot of rye upon the iris, discovered by M. Comperat; he says that in excessive 
dilatation from the use of belladonna, powdered ergot of rye, taken like snuff, has 
the property of contracting the pupil. Dr. M'Evers tried its effects on several per- 
sons, whose irides were strongly under the influence of belladonna, and in no 
case did the ergot cause any change when employed on the same day with the 
belladonna, but in every case, on the subsequent morning, whilst the pupils were 
still largely dilated, the ergot had a marked effect after a few minutes. Thinking 
with Comperat, that our knowledge of this property of the ergot may be taken 
advantage of when the pupil is preternaturally dilated from other causes, he tested 
its efficacy in the following case of mydriasis. 

A man aged 50, had spent the greater part of his life in tropical climates, but 
returned home with a good constitution. On getting out of bed three weeks ago, 
he observed excessive lachrymation of the right eye, which has continued since, 
together with impaired vision. The eye is free from vascularity or pain of any 
kind, and looks healthy in all its parts, except the iris, which presents the appear- 
ance of a narrow ring, so largely is the pupil dilated; the iris is perfectly immov- 
able. 

A few pinches of ergot contracted the pupil considerably in a few minutes, whilst 
a few additional pinches taken on the following morning, reduced the pupil to its 
normal standard, the iris assuming the lively motions of healthy action ; thus, in 
a day, completing, as far as the pupil is concerned, the cure of a disease which 
Demours, and other writers on ophthalmic surgery, tell us cannot be accomplished 
by a six months' treatment. — Bub. Quart. Journ., Nov. 1848. 

[We have employed the powdered ergot in two cases of mydriasis and we 
think with advantage; but the effects were by no means so striking as observed 
by M. Comperat or even by Dr. M'Evers ] 



MIDWIFERY. 

69. On the Mammary Secretion as a Sign of Pregnancy. — Dr. Alexander Peddte, 
in an interesting paper in the Monthly Journal (Aug. 1848.) states that " From the 
experience of upwards of two years, during which my attention has been directed 
to the subject, I feel convinced that the most invariable sign of gestation prior to quick- 
ening, is to be found in the presence of fluid in the breasts, — with the limitations that 



1849.] 



Midwifery. 



211 



shall hereafter be noticed ; and, consequently, that the absence of the secretion 
will afford the surest evidence that the suspension of the catamenial flux is an 
abnormal deviation from nature's course. The sign is indeed, to some exient, an 
old and popular one, but not to be despised or overlooked on that account, nor to 
be set aside without consideration. Although some eminent writers on obstetric 
medicine have passed it by without any notice, and others have pronounced it 
1 an evidence scarcely of any value at all,'* I would earnestly invite an unpreju- 
diced attention and scrutiny of the subject; for my own experience in judging from 
the sign, when there was an opportunity of watching the course of events, war- 
rants in me stating, that I have never found it fail in regard to those who were 
gravid for the first time, or in regard to those who were not pregnant at all. And 
although the greater number of cases of pregnancy in which I have had an oppor- 
tunity of applying the test, have been advancing in the fourth month, yet so early 
as the end of the second and the beginning of the third months the sign has held 
good. It is not, however, until about the termination of the third, and more generally 
in the currency of the fourth months, that the medical man is consulted, when the 
repeated non-appearance of the menses attract the notice, and excite the interest 
or fear of the individual, according as the moral feelings may be affected. And, 
as the value of the sign is not insisted upon in its application to other than first 
pregnancies, within this limitation is included the class of cases, which, above all 
others, are of most frequent occurrence and importance, and which occasion most 
trouble and anxiety to the practitioner. 

" Perhaps the value of this sign in the early months, has been doubted or under- 
estimated, in consequence of not observing fluid trickle from the nipples, as it 
frequently does in the last month of pregnancy. I believe that this will rarely 
happen in the commencement of a first gestation. The fluid must be brought ; 
and the method of obtaining it, under doubtful circumstances, is to press the finger 
and the thumb firmly on the mammary gland, a little beyond the margin of the 
areola, and then draw them to the point of the nipple w T ith a stripping and express- 
ing movement. This repeated three or four times, will certainly bring fluid if any 
be present; and a single drop will suffice to prove the nature of the case. A little 
moisture from the sebaceous follicles of the areola, which is sometimes produced 
during these efforts, must not be mistaken for a lactic secretion. I believe that 
this kind of exudation, which may occur in ordinary circumstances, has actually 
led, in some instances, to the rejection of the sign which I am now advocating. 
It is recommended also, that if a drop of fluid is not obtained from one nipple, 
the other ought to be tried, as the orifices of the lactiferous tubes are sometimes 
more narrow or glued up in the one than in the other breast, and in primiparse 
this is more particularly the case. 

" In the early months of a first pregnancy the secretion has seldom the external 
appearance of milk, but is serous looking, and often very viscid and syrupy. 
When submitted, however, to the microscope, the characteristic milk globules 
will at once be detected; and these will be seen agglomerated en masse, the solid 
portion being at this period in a large ratio to the fluid, which latter is also pecu- 
liarly glutinous. Mixed with thesegroups will be perceived au abundance of large 
oil globules and colostrum granules, as in the green milk of recent parturition. 
There are sometimes found also a few epithelial lamellas, which have been sepa- 
rated from the lining membrane of the excretory ducts, and which have either 
not been transformed into colostric masses, or, if this has been so, they have 
already parted with their mucoid and granular contents. 

" Of the annexed plates, II. and III. are exact copies of the secretion taken in 
the third and fourth months of gestation ; the first, from a young unmarried woman, 
who attempted to conceal her pregnancy ; and the second, from a young unmarried 
lady, who was not aware of her own condition, and whose station in life, educa- 
tion, and previous good conduct, were a protection against an early suspicion of 
her state. Both w T ere convicted by the milk test, when the ordinary signs excited 
only a vague suspicion; both soon confessed their transgression ; and both were, 
on the strength of the opinion given, immediately placed in the bonds of lawful 
wedlock. 



* Churchill, Theory and Practice of Midwifery, p. 107. 



212 



Progress of the Medical Sciences. 



[Jan. 



" The value of the lactic secretion as a sign of pregnancy has apparently been 
disregarded by some, in consequence of the very exceptional cases recorded, more 
especially the example given by Baudelocque, of a girl eight years old who was 
able at pleasure to milk her own breasts, and another somewhat similar mentioned 
byBelloc; and this under-valuation may also be ascribed to the statements of 
other writers regarding the exudation of milk, even from the breasts of adnlt 
males* Such cases, however, even if well authenticated, are worthy only of 
being ranked among other physical monstrosities occasionally met with : and even 
instances less wonderful, as the appearance of fluid in the breasts of those who 
are not, and never were pregnant, ought, I think, to be viewed as rare examples 
of nature's freaks — her exceptions, and not her rule.f While I do not doubt that 
such cases have occurred — though I think some of them are not unlikely to have 
been the follicular exudations already noticed—in the very numerous examinations 
which I have made with a view to detect, if possible, the existence of fluid in the 
mammse of the non-pregnant, I have not as yet met with an instance of the kind. 
In many instances of unmarried women of unblemished character, who were suf- 
fering from menstrual obstructions, and of married women under similar circum- 
stances, who never were gravid, I have not been able by expression to obtain a 
single drop of fluid ; and in many instances also of both classes where there was 
perfect uterine health, I have been equally unsuccessful. 

" Beyond the limitation of first pregnancies, I would not desire to urge the appli- 
cation of the milk test; for when a woman has once suckled, the fluid is apt to 
linger in the breasts a considerable time after weaning, and the mammse continue 
performing a partial function, — in many instances, doubtless, owing to the daily 
operation of maternal sympathies. In general, I have found the fluid easily at- 
tainable from three to six months after weaning, and the restoration of the cata- 
menia. — although in one instance which occurred lately, it had completely vanished 
before the expiration of two months. On the other hand, I found it present in one 
case after the lapse of two years; and I believe that it may exist at a still later 
period, although in several women still within a child-bearing age, I have been 
unable to procure a single drop of fluid at the distance of four years from the date 
of last weaning. It may, however, readily return at a much later period in the 
case of those who have once given suck, when the uterus becomes distended with 
any false conception or hydatid accumulation ; and very probably it may do so 
under similar circumstances, in those who never were pregnant. An instance of 
the former kind came lately under my own observation. The patient had not had 
a child for nine years, and while the uterus gradually enlarged, and the abdomen 
became distended, so as to simulate pregnancy, and lead to the necessary prepa- 
rations, imposing on myself at an early, and on another physician at a later period, 
the secretion was most abundant. The time of expected confinement, however, 
passed by to the extent of several weeks, and the mystery was solved by a sud- 
den and large discharge of water. 

" When milk is procurable a few months subsequent to weaning, and the 
woman not again gravid, I have found it existing only in small quantity, one or 
two drops, viscous and cream-like to the unaided eye; and to the microscope it 
presents milk globules in sparing number, often ill formed, adhering together, or 
to large oily drops (the creamy part) , or to ihe epithelial scales, mucoid, and other 
foreign matters, which are generally present in abundance — as is seen in Fig. VII., 
1 and 2. The secretion in such circumstances affords, I think, some good diag- 
nostic marks, by which it may be readily distinguishable from fluid obtained in 
the early months of a new gestation. The latter is comparatively rich in milk 

* Carpenter, in his Treatise on Physiology, p. 626, refers to an instance of this kind, 
as described in the Phil. Trans., vol. xli. p. 813; another by Captain Franklin, in his 
Narrative of a Journey to the Polar Sea, p. 157; one by Humboldt, in his Personal Nar- 
rative, vol. iii. p. 58; and a fourth by Dr. Dunglison, in his Physiology, vol. ii. p. 417. In 
the last-mentioned case, the subject, a man of colour, is said to have actually officiated as 
a wet-nurse ! 

■f In this light I would regard the single instance which M. Donne has noticed, of a 
little fluid found by him in the breast of a young woman said never to have been preg- 
nant, and which presented the microscopic character of milk: p. 441. 



1849.] 



Midwifery. 



213 



globules of normal appearance, and of better medium size, having abundant colos- 
trum, and few, if any, membranous scales, or debris of disintegrated textures — 
(Figs. II. and III.) ; and, as the full term of gestation is approached, the secretion 
increases in quantity, and becomes better in quality, more evidently suited for the 
important object in prospect. — (Figs. IV. and V.) 

" From the above notices, I think it may be admitted that the sign of pregnancy 
now advanced, although of most value in the diagnosis of a first pregnancy, is 
not without a certain amount of importance in the recognition even of a subsequent 
gestation; and I should decidedly affirm, that in general it is more certain in its 
information as a corroborative evidence of pregnancy than the papular areolae, 
which, when once darkened, seldom lose much of their colour, or of the follicular 
glands, which retain, in a great measure, their size after they are once developed. 

11 Compared with any of the ordinarily recognized signs for distinguishing a first 
pregnancy from a simple suppression of the menses, before any bulk or impaction 
in the iliac and hypogastric regions can be detected by the eye or hand, or before 
the ear can discover the unmistakable sounds of placental and fetal circulation, 
there will be found, 1 think, far fewer exceptions to the milk test. As regards the 
sign of morning sickness, I have had under advice many cases of obstructed men- 
struation from causes unconnected with gravidity, yet attended with disturbance 
of the digestive organs to a great extent, of which daily recurring sickness — most 
frequently in the morning — formed a part : while, on the other hand, in very fre- 
quent instances this symptom has been entirely wanting in those really pregnant. 
Then, again, the signs taken from the aspect of the mamma, are most variable and 
contradictory. While I have often observed women with fair complexions who 
had large breasts, well marked areolae, numerous and large follicular glands, and 
prominent nipples, suffering merely from suppression of the catamenia, I have 
seen not a few with dark or sallow complexions, who, although undoubtedly 
pregnant, had small breasts, small nipples, areolae scarcely distinguishable from 
the surrounding skin, and few or no sebaceous glands * Were it not to extend 
this communication to too great a length, I might give notes of many cases illus- 
trating the variability and uncertainty of these signs. I shall, however, content 
myself with noticing only one example — which is interesting in several other re- 
spects. The patient was brought before the Obstetrical Society in December 
last,f by Dr. Simpson, chiefly to show the impossibility of diagnosticating preg- 
nancy in her case, in so far as the appearance of the mammae were concerned. 
The woman had dark brown hair and a sallowish complexion; she had been four 
years married, and was then, although presenting no traces of areolae or glandular 
follicles, decidedly in the seventh month of her first pregnancy, complicated with 
large fibrous tumours projecting from the anterior wall of the uterus. Now, it is 
an interesting fact, that before the fourth month was complete, counting from the 
last menstrual period, I had carefully examined this patient, who called on me on 
account of the tumour of the abdomen; and, in consequence of being able to ex- 
tract a little fluid from the nipples, I expressed my conviction that she was preg- 
nant, though I was then at a loss to say whether the tumour was a growth from 
the uterus or an extra-uterine conception. On a second examination, about one 
month subsequently, 1 was able by the stethoscope to verify the opinion formerly 
given as to the fact of gravidity, and I know that she has "been since confined at 
the proper term of gestation. 

" As regards the evidences of pregnancy from abdominal exploration previous to 
the commencement of the fifth month, there is always ground for much doubt and 
fallacy. For it is not till then that quickening occurs; and in cases requiring a 
special scrutiny, this is a symptom which will, in all probability, be concealed. 

* In so far as the appearance of the breasts are concerned, it may be curious to notice 
here, that I had under my care lately an adult male of fair and ruddy complexion, afflicted 
with disease of the heart, whose breasts were full, slightly pendulous, surrounded with 
exceedingly dark areolte, numerous follicles, and whose nipples were large and promi- 
nent. On several previous occasions I have met with cases somewhat similar; and in 
fact the variety in the colour of the male areola, the development of its follicles, and the 
size of the nipple, is a matter of daily observarion. 

f Mouthy Jou rnal of Medical Science, March 1848, p. 693. 



214 



Progress of the Medical Sciences. 



[Jan. 



It is not until then also, that the iliac and hypogastric regions assume a visible ful- 
ness, and give to touch a feeling of firmness and impaction; and, although this 
enlargement was then apparent, it might be owing to causes very different from 
gravidity. Auscultation, too, comes after this period only to be of any avail, — 
and perhaps not even until a considerable time subsequently, to the ears* of many ; 
and did delicacy oppose no obstacle to uterine examination, until now the finger 
or the speculum of the most experienced obstetrician, may be unable to detect 
the true nature of the case. 

li The presence in the urine of what has been called — but absurdly so — Kiestein, 
is a very important evidence of the existence of pregnancy. It has been found 
by Dr. Golding Bird* as early as the second and third months after conception; 
but as it appears to exist only in small quantities in the early months, as the urine 
must be allowed to settle for a number of days before the peculiar greasy, cheese- 
odoured pellicle can be obtained, it is evident that this is not a test which can be 
otten or conveniently employed, especially in the most important class of cases 
in which the physician is consulted. The fact of the unvarying existence of this 
substance, however, may, I think, be assumed as strongly corroborative of the 
value of the milk test, as it shows the presence of the secretion at an early period; 
for without doubt, as Dr. Bird expresses it, 'the imperfectly formed secretion of 
milk, not having a ready exit by the mammas, is taken up into the circulating 
mass, is separated by the kidneys, and eventually escapes from the body in the 
urine. 'f With the aid of the microscope, I have fully satisfied myself that this 
product contains some of the elements of milk — the largest amount of which is 
probably caseous matter, mixed with crystals of the triple phosphate of magnesia." 

70. Protracted Lactation. — Dr. Mom mentioned to the Edinburgh Obstetric Society 
(June 14th) the case of a married lady, who, from certain reasons, was unable to 
nurse her children, but in whom the secretion of milk was after each confinement 
unusually protracted, notwithstanding the means used to discuss it. Starvation, 
purgatives, diuretics, diaphoretics, and alteratives, as internal remedies, and local 
astringents of various kinds were used, without in the least diminishing the secre- 
tion, or having any effect further than that of weakening the patient : so that latterly 
the only means employed were of a tonic nature, to sustain her strength. The 
secretion continued from one confinement till about the third month of the suc- 
ceeding pregnancy, after w r hich it almost ceased; after her second confinement it 
continued eighteen months; after her third, twenty-four months; after the fourth, 
twenty-five months; after the fifth, about twenty-four months, when she had a 
miscarriage, and since then has had no children. A circumstance that rendered, 
this case peculiarly distressing was, that after her first confinement she suffered 
from a severe mammary abscess, which, by the practitioner then in attendance, 
was opened close to the nipple. From this wound the milk continually flowed, 
and as it never healed up, it was impossible to receive the milk from this breast 
into any convenient reservoir; so that the lady was kept in a constant state of dis- 
comfort, her dress, notwithstanding the use of oiled silk and M'lntosh cloth, being 
completely saturated with milk. The skin over the abdomen and left side was 
from the same cause much irritated, and in warm weather partially excoriated. 

Dr. Peddie knew of a woman having nursed uninterruptedly for three years. — 
Monthly Journal, Sept. 1848. 

71. Sore Nipples and their Treatment. By Drs. M'Clintock and Hardy. — Sore 
nipples may not only incapacitate a woman from nursing, — a deprivation in itself 
often sufficiently grievous, — but they may, as we have before observed, give rise 
to mammary abscess, from an extension of the inflammation backwards, along 
the ducts, to the substance of the gland. This, in point of fact, is the great danger 
to be apprehended, and every other consideration should give way to it. 

When there is reason to dread such a result, the child is entirely withheld from 
the affected breast, which is kept soft by rubbing, and if the nipple itself appear 
to be the seat of any inflammation, a bread and water poultice is applied to it. 

Of the various topical applications for sore nipples employed in this hospital, it 



Guy's Hospital Reports, Vol. V. pp. 16 and 25. 



t Ibid , p. 22. 



1849.] 



Midwifery. 



215 



may be well to mention two or three whose value has been established by long 
experience. 

Amongst these the tincture of catechu holds a high place, and has been found 
a very excellent astringent; like the other remedies of this class, it is best adapted 
for the simply excoriated or abraded nipple. Nearly similar to it is the solution 
of pure tannin, so highly recommended by Mr. Druitt. It is made by dissolving 
five grains in an ounce of distilled water. We have not observed it to possess 
any superiority over the catechu, except in being more cleanly. The following 
is a favourite lotion with Dr. Johnson, who has been in the habit of using it for 
many years: — R. Sub-borat. sodse, £ii; Cretse precipitat., §i; Spiritus vini, Aquse 
rosae, aa ^iii. M. fiat lotio. 

This may be applied alternately with the following ointment, or the latter may 
be used alone: — R. Cerse albas, ^ivss; 01. amygdal. dulc, gi; Mellis despumat. 
~ss; Dissolve ope caloris, dein adde gradatim ; Bals. Peruviani, 3iiss. M. fiat un- 
guentum. 

In some cases we have seen benefit result from the use of tincture of galls and 
compound tincture of benzoin (Friar's balsam), in equal proportions. 

It is always well to have in mind a number of these different preparations, for 
it not unfrequently happens that one will answer our purpose when others have 
failed. For fissured nipples some authors strongly advise the application of solid 
nitrate of silver: but our experience does not permit us to speak of it. Dr. John- 
son thinks it is sometimes a good remedy in such cases, at a remote period of 
delivery; but that during the puerperal state its use is not advantageous, as it is 
apt to be followed by mammary abscess. — Practical Observations. — Lond. Med. Gaz. } 
Sept. 1848. 

72. Fissures of the Nipples. — M. Jose Leon advises all pregnant women who have 
reason to fear chapped nipples, to use during the month preceding delivery, once 
a day, the following liniment, the breasts being previously washed with tepid 
water: — R. Tannate of lead, grammes iv; Simple cerate, grammes xxx; Oil of 
roses, drops ij. The bosom should be immediately covered with a compress of 
soft linen. — Gazette des Hopitaux, Sept. 14th, 1848. 

73. Rupture of an Impregnated Uterus, from a collection of Pus in its Cavity. — By 
Dr. Guzzo, of Naples. — A woman, 33t. 34, liable from puberty to uterine pains 
and irregularities, married, but childless, came under Dr. Guzzo's care in June, 
1837, when he found the uterus as enlarged as at the fifth month of pregnancy, 
and, in a twelvemonth after, it nearly had reached the umbilicus, occasional co- 
lourless discharges being observed. She continued to live until 1841, the tume- 
faction still increasing, when, after the use of a purgative, peritonitis was induced, 
and in a few hours she died. A large quantity of pus was found in the abdomen, 
and the uterus adhered to its parietes from the pubes to the umbilicus, filling up 
the iliac and hypochondriac regions, and was covered by the omentum. The 
cavity of the womb contained an enormous quantity of inodorous white pus, va- 
rious irregular hypertrophic formations being developed on its inner surface. Its 
walls were thickened, and contained in their substance tubercular masses, vary- 
ing in size from an olive to a walnut, some being crude, and others suppurating. 
Some of these tubercular abscesses were just on the point of opening into the 
cavity of the uterus, and a rupture had taken place at the posterior surface of the 
organ. — Brit, and For. Med. Chirurg. Rev., Oct. 1848, from Archives Generales. 

74. Statistics of the Induction of Premature Labour. — Dr. Hoffman observes that, 
favourable as he is to this operation in appropriate cases, his present statistical 
investigations convince him that it is resorted to with unnecessary frequency. 
Thus, in the kingdom of Saxony, with only a million and a half inhabitants, it 
was resorted to 64 times in the year 1839 alone; and Dr. Ramsbotham has em- 
ployed it 72 times, which he thinks far too often for any single accoucheur to re- 
quire its aid. He should bear in mind, however, that Dr. Ramsbotham has one 
of the largest consultation practices in this immense metropolis. Dr. Hoffman has 
collected 524 cases, and, as the references to all these are supplied, his paper is 
one of considerable bibliographical utility. Of these cases, 271 were due to Ger- 



216 



Progress of the Medical Sciences. 



[Jan. 



man, 192 to English, and 17 to French practitioners; but when we find he only- 
assigns 3 cases to Americans, we see how defective his researches in that quarter 
must have been. 

The age of the mother is recorded in but 146 cases, the youngest being 17, and 
the eldest 44 ; in more than one-half of the entire number she had reached or 
passed her 30th year. Of 258 cases, in only 49 was the operation resorted to in 
a first pregnancy. Although the repetition of the operation in the same woman 
must have been no infrequent occurrence, the author finds records of this only in 
34 cases, in some of which it was performed three, four, or more times. The 
stature of the women is recorded to have been oftener small than large, as would 
be expected, from the greater frequency of small and rickety pelves in conjunc- 
tion with the former. In comparatively few cases has the author found the indi- 
cations for the operation furnished, but justly concludes that, in the bulk of cases, 
it has been instituted on account of narrow pelvis. In only 68 cases does he find 
that preparatory treatment — such as baths, tepid injections of the vagina, friction of 
the abdomen, &c. — have been put in force; an omission, he considers, much to 
be regretted. 

In nearly two-thirds of the cases, the mode of operation is given. Of the more 
generally admitted of these, the use of secale cornutum is recorded in 45 cases, 
almost entirely by English practitioners. In these, 23 children were born alive, 
15 dead; and, of the whole 38 noted. 12 others died within 36 hours after birth. 
The Hamiltonian plan of detaching the membranes, modified by several Germans, 
is exceedingly tedious. The introduction of prepared sponge is a favourite mode 
with the Germans, and was employed in 70 cases. In 56 cases in which the 
condition of the child was noted, 42 were born living. Puncturing the membranes 
is the oldest mode, and has been resorted to in 180 cases, and, indeed, doubtless 
in many of the others not specified. It is beyond all others the easiest, quickest, 
and most certain means of inducing premature labour, but has been received with 
much more favour in England than in Germany. By it, however, a far less pro- 
portion of children are saved than by the use of the sponge. The fates of 178 are 
specified, of which 103 were born alive, 12 still-born, and 63 bom dead. 

As to the presentation of the child, it is specified in only 120 cases; and of these 
45 were cephalic, 75 non-cephalic presentations. This proportion is, however, 
delusive ; as it is nearly certain that all the cases not specified were natural pre- 
sentations. Even allowing this, we still find every seventh case a preternatural 
one. In the 75 cases, the great number of 19 cross-births are noted. In 84 cases 
the completion of the labour required assistance ; in 36 by the forceps, 18 by turn- 
ing, and 11 by perforation. 

The fate of the child is recorded in 373 cases, in which 250 were born living, or 
recovered from asphyxia, and 123 dead. But in 77 of these cases, the child died 
from circumstances which could have had no reference to the operation, as faulty 
position, perforation, &c. Of 192 of the children born living, further reports state 
that 127 continued to live, and 65 had died — 28 in the course of six hours, 6 in 
twenty-four hours, and the rest at periods varying from a day to a year or more. — 
Neae Zeitschrift fur Gcburtskunde, vol. xxiii. pp. 161-222, and 371-436. 

[We have thought it right to give a few of the results detailed in Dr. Hoffman's 
long paper, the general conclusions from which would seem to be, that if a dis- 
charge of the liquor amnii is the most certain mode of inducing premature labour, 
other modes save a large proportion of children. Still, this is uncertain, owing to 
the paucity of facts adduced, compared to those which have really occurred ; for, 
valuable as is the numerical system, when operating upon large bodies of facts, of 
the whole of which the entire particulars are similarly recorded, its partial applica- 
tion is of little use, and may even give rise to the most erroneous conclusions.] — 
Brit, and For. Med.-Chirurg. Rev. 

75. Prolapsus of the Funis, at the second month of Pregnancy. — Mr. LB. Brown 
related to the Westminster Medical Society (Oct. 21) a case of this rare pheno- 
menon. The subject of it was thirty years of age, and the mother of three chil- 
dren. She was threatened with abortion, and after two or three attacks of hemor- 
rhage, attended with expulsive pains, in one of these the cord was found to be 
pesenting in a loop. The following day a severe pain came on, and the cord 



1849.] 



Midwifery. 



217 



burst. This was followed by profuse hemorrhage, and the expulsion of the faRtus. 
The placenta was found to be nearly bloodless. In consequence of the severe 
pain experienced in removing the placenta, the patient was placed under the in- 
fluence of chloroform. It was quite successful, and she is doing well. — Lancet 7 
Nov. 4 ; 1848. 

76. Quinine as prophylactic of Puerperal Fever. — The idea that quinine is pre- 
servative against puerperal fever was started by M. Alphonse Leroy, of Rouen, in 
1793. M. Leudet put it to the test in an epidemic which occurred in 1843, and 
lasted for three months, administering it before the accustomed period of the first 
appearance of the malady. For this purpose he employed the quinine in 15 grain 
(one gramme) doses, and in the few cases it was then tried in no fever followed. 
He repeated his experiments in two other epidemics, occurring in the years 1845 
and 1846, when he found that those submitted to this medicine did not contract 
the fever. To give the statistics: — Of 83 women who entered the Hotel Dieu de 
Rouen, between September, 1843, and January, 1844, 74 took no medicine, and 
21 of them were seized with puerperal fever, whilst the remaining nine w r ere 
dosed with the quinine, and escaped contagion. Again : between July 8th and 
August 9th, 1845, 26 deliveries occurred: 11 women were submitted to no medi- 
cation, and eight of them were attacked with the epidemic fever; of the 15 others 
treated with sulphate of quinine, one only caught the disease. Lastly, between 
the 9th of March and the 21st of April, 1846, 36 women were delivered: of the 
19 who took no quinine, 11 were attacked; of the 16 submitted to its action, only 
one was seized with fever. 

The following is the manner in which M. Leudet employs the quinine: — As 
soon as the newly delivered woman has a little recovered the shock of the child- 
birth — viz., in about four hours after delivery, 15 grains of the medicine are given 
in the course of the 24 hours, in three portions. The same quantity is prescribed 
the next day, but on the third day it is diminished to ten grains, and the same dose 
is persevered in until the usual period of the accession of the fever has passed b}^ 
up to about the sixth day. The occurrence of milk fever is not always an indica- 
tion to stay the quinine, for in very many cases that febrile disturbance is very 
slight. 

The plan of using quinine as a prophylactic has been subsequently adopted in 
Paris by M. Cazeaux, who could, from his experience, however, make no report 
of its efficacy. Nevertheless, any remedy holding out such a promise, in so fear- 
ful a disease, should not be thrown aside until after a careful and repeated trial. 
On the other hand, hygienic measures must be looked upon as by far the best 
safeguards, both against the development and the propagation of puerperal fever. 
Lancet, Oct. 7, 1848. 

77. Medicated Pessaries. By Dr. Simpson. (Proceedings of Edinburgh Obstetric 
Society.) — In diseased states of the cervix uteri and vagina, medicinal substances 
had been applied locally to those parts under various forms, but principally, either 
in a solid state (as nitrate of silver, potassa, &c), or in a liquid form (as in the 
great varieties of medicated injections in common use in leucorrhcea, &c.) When 
thus used, the local application was temporary, and applied for a few minutes 
only. But in various forms of disease it seemed an indication of no small im- 
portance to have the medicated substance applied continuously, and not tem- 
porarily. Medicated pessaries, which Dr. Simpson had first introduced into prac- 
tice several years ago, and which had since been extensively adopted by various 
practitioners in London and elsewhere (see description of them published by Dr. 
Stafford Lee, Dr. Oldham, &c), enabled us to fulfil this indication. By their use, 
for instance, we could keep the cervix uteri, when ulcerated and indurated, con- 
stantly embedded in mercurial or iodine ointment for weeks, and sometimes with 
the most marked benefit and success. They fulfilled another indication in cases 
of irritation and inflammation of the mucous membrane of the cervix uteri and 
vagina. They kept the opposed diseased surfaces from coming in contact, and it 
was well known how important a matter this was in the pathology of mucous and 
cutaneous surfaces. 

Dr. Simpson had been in the habit of applying a variety of substances in the 



218 



Progress of the Medical Sciences. 



[Jan. 



form of medicated pessaries, particularly zinc and lead ointment, &c, as simple 
emollients; mercury and iodine as discutients (and particularly the iodide of lead) ; 
tannin, alum, and catechu, as astringents; opium, belladonna, &c, as anodynes. 
The pessaries were made of the size of walnuts, and could be easily introduced 
by the patients themselves; one or two in the twenty-four hours. They were 
composed of the medicine used, mixed up in the form of an ointment, and brought 
to a requisite degree of consistence with one or two drachms of yellow wax to 
the ounce of ointment. Messrs. Duncan and Flockhart, druggists, had found 
the following proportions requisite in the subjoined forms, (those in most frequent 
use in Edinburgh;) and they might serve as models for the others. After being 
made up in the proper form, they were usually coated by the druggists with a 
firmer covering, by dipping them into an ointment made up with wax and resin, 
kept liquid by heat. About an ounce of the different ointments made four balls. 

1. Zinc Pessaries. — R Oxydi zinci gj; Ceras albae gj; Axungise gvj. Misce, et 
divide in pessos quatuor. 

2. Lead Pessaries — R Acet. plumbi. gss; Cerse albas giss; Axungise gvj. Misce. 

3. Mercurial Pessaries. — R Unguent, hydrarg. fort. 3ij ; Ceras flavas jij ; Axungise 
§ss. Misce. 

4. Iodide of Lead Pessaries. — R Iodidi plumbi. ^j; Ceras flavse h)v; Axungise 
^vj. Misce. 

5. Tannin Pessaries. — R Tannines ^ij; Ceras albas J}v; Axungise sjvj. Misce. 

6. Alum and Catechu Pessaries. — R Sulph. aluminis £j; Pulv. catechu gj; Ceras 
flavas £i ; Axungise gvss. Misce. 

7. Belladonna Pessaries. — R Extr. belladonnas >}ij; Ceras flavas giss; Axungise 
gvi. Misce. — Month. Journ. and Ret. Med. fyc, June 1848. 

78. Plaster Belt in Abdominal Tumours. By Dr. Simpson. (Proceedings of Edin- 
burgh Obstetric Society). — Dr. Simpson stated, that patients affected with pedicu- 
lated ovarian tumours, large fibrous tumours of the uterus, &c, often suffered from 
the morbid masses being loose and mobile, and impinging on the bladder, &c, 
in different positions of the body. Patients sometimes instinctively applied their 
hands to the tumours, under such circumstances, to steady and fix them. In these 
cases different means had been tried, with the view of preventing the tumours 
rolling and moving — such as various bandages, air-pads of Mackintosh cloth, &c. 
The best and simplest means, however, consisted in surrounding the whole trunk 
with a continuous belt of lambskin or chamois leather, eight or ten inches deep, 
and shaped and sewed so as carefully and exactly to fit the loins and lower part 
of the abdomen of the patient, like a common abdominal bandage, and embossed 
in front so as to contain and includ'e, as in a bowl or cup, the protuberant portion 
or portions of the tumour. To fix the belt, its interior was spread with a plaster 
composed of one part of adhesive to two parts of soap plaster. It generally gave 
the patient much relief; abated the feelings of abdominal weight and pressure 
and pain in the back; held the tumour steady; and could be applied so as even to 
compress it. In other cases where no tumours were present, but the abdominal 
parietes and contents were relaxed, or the spine weak, the same form of plaster 
often afforded a great degree of comfort and relief, and enabled patients to take 
exercise, &c, when, otherwise, they could not without fatigue and suffering. 
They generally required to be removed and renewed every four or six weeks. — 
Ibid. 

79. Employment of Chloroform in Midwifery. — Dr. Simpson gave a long report 
and detailed communication on the employment of chloroform in midwifery, 
stating that he had used it constantly, and with the best results, in his own practice 
since November; mentioning the rules required to be attended to in its exhibition ; 
answering the supposed objections to its use, &c. &c. He read numerous com- 
munications and reports regarding its employment, from Dr. Grigor of Nairn, 
Professor Dyce of Aberdeen, Mr. Lawrence of Montrose, Dr. Paton of Dundee, 
Dr. Anderson of Glasgow, &c. &c, showing that a great number of persons had 
been already successfully delivered without pain or suffering under the use of 
chloroform during the last six months. 

Drs. Moir, Malcolm, Leith } Carmichael, &c, stated to the Society, some verbally, 



1849.] 



Midwifery. 



219 



and others in writing, the uniform and successful results which they had met with, 
employing it, as they did, constantly in their practice, and in all cases of labour. 

Mr. Crisp of London slated, that though a stranger, he was induced to rise were 
it for no other purpose than 10 say that, after having attended the meetings of many 
a medical Society, he had never till to-night seen one that was unanimous in 
opinion on any topic. He had come to Edinburgh a fortnight ago, and now en- 
tertained a totally different opinion about chloroform from what he did when he 
arrived; for he had now seen it constantly and most successfully employed in the 
hospital and elsewhere. At the same time, although this had been the result 
of additional experience on his own mind, he was not disposed to blame, but, on 
the contrary, to commend the skepticism which had been shown by many most 
eminent men in London and elsewhere, on this subject, which he thought was 
no more than justified in relation to an agent of such a novel kind, and so import- 
ant in its practical application. He believed that this skepticism had not its origin 
in any exclusive or bigoted feeling, but would be overcome as soon as the facts 
came to be as well known in London as they are in Edinburgh. 

Dr. Bennett considered it probable, that one of the reasons chloroform was not 
much used out of Edinburgh, was the impurity of the article administered. It 
was not long ago that Dr. Clay of Manchester stated to the Society, that 
although he had frequently seen it given in that town, he had never witnessed its 
proper effects produced until he came to Edinburgh. Mr. Crisp from London had 
just made a similar statement. Dr. G. Wilson had lately informed him, that even 
the chloroform manufactured in Edinburgh was not so pure as it might be, and 
that he had lately purified some which produced the full effect more rapidly, and 
with a smaller quantity, than that in ordinary use. He (Dr. B.) conceived that 
the purity of the chloroform was not sufficiently attended to by those who had tried 
it, and that those who would not, had better, like Dr. Clay and Mr. Crisp, come and 
see it given in Edinburgh. 

Dr. ^Simpson observed, that he believed the want of success in England was 
owing also to another cause. From what he had learned, he was quite convinced 
that our English brethren, in using chloroform, often stopped altogether at that 
point which really constituted the true commencement of the effects of the inha- 
lation. Immediately before the chloroform produced anaesthesia, more especially 
if there was any noise or disturbance, it not unfrequently excited the patient, who 
would talk incoherently for a moment or two, beg the inhalation to be suspended, 
perhaps struggle to get free from it, and have his arms and legs thrown into a state 
of strong clonic spasms. In Edinburgh, we all sufficiently know that these symp- 
toms indicate merely that the patient is about to come under the full influence of 
the vapour, and that, in a minute or so, these symptoms will pass, and he will 
immediately be completely anaesthetic and completely unconscious. But in Eng- 
land these premonitory symptoms seem to have been often regarded as very 
alarming, and all attempts at further inhalation stopt, exactly where and when the 
dose of the vapour should have been increased. And in the English journals 
such cases have been repeatedly and gravely recorded as instances of delirium, 
and spasms, and convulsions, and failure. They are not more anxious, or deserv- 
ing of attention, than the same symptoms would be in a case of hysteria, and are 
quite transient if the inhalation is only persevered in. Dr. Simpson added, that 
now, amongst many hundred patients, he had never yet met with one instance in 
which any person was insusceptible of the full effects of the chloroform. He 
knew that the experience of many of his brethren around him went to the same 
effect. Nor, in any one case, had he seen any marked bad effect from the full 
use of the chloroform. Deaths will occur after operations, and sometimes even 
during them; but every death during an operation was not, as some of late in the 
south have argued, from chloroform. A gentleman near him, Dr. Paterson, some 
weeks ago opened with his lancet a large abscess in a child's neck. There was 
no hemorrhage; butin a minute or two, at most, after the incision was made, the 
child was dead. An English jury might possibly have anxiously tried to bring it 
in as a case of death, probably from chloroform. But it certainly was not so, for the 
very simple reason, that no chloroform whatever was used, the incision being 
considered too slight to require it. Dr. Simpson a?ked Professor Miller and Dr. 



220 



Progress of the Medical Sciences. 



[Jan. 



Duncan to state the extent to which they used chloroform in their public and 
private surgical practice. — Proceedings of Medico- Chirurgical Soc. of Edinburgh, in 
Month. Journ., July, 1848. 

80. Case of Retention of a Foetus in the Uterus for Eleven Years. By Dr. Vondor- 
fer. — This woman was forty-nine years of age, and had already borne two child- 
ren. She was busily threshing corn, when she was seized with violent pains in 
the back, resembling those of labour. After they had continued for two hours the 
waters broke, and were discharged. For fourteen days she lay almost entirely 
upon her knees and elbows. At the end of this time the pains had almost ceased, 
but still in lying on her back she kept her knees well drawn up. Three weeks 
afterwards she was seized with a flooding, which was easily stopped. After this, 
there was a constant fetid discharge from the vagina, which continued more or 
less for eleven years, and occasionally some foetal bones were discharged with 
great pain. During most of this time the woman was able for her work, and in 
good health. At the end of eleven years she was again forced to betake herself 
to bed, and she died, after some time, with the symptoms of purulent infection. 
On dissection, the uterus was found adhering to the anterior wall of the abdomen, 
and it contained the remains of the putrefied fetus, along with its numerous bones. 
Month. Retrosp., Dec, 1848, from Schmidt's Jahrbucher, Nov. 9, 1848. 

81. Case of Spontaneous Amputation of the Forearm, and Subsequent Rudimentary 
Regeneration of the Hand of the Foetus . (Proceedings of Edinburgh Obstetric Soc.) 
— Dr. Simpson showed the society a girl, aged eleven, who had been born wanting 
the left upper extremity from a short way below the elbow-joint. The arm of this 
side was of the natural size and form; but the forearm consisted merely of a 
stump about two inches long. It had all the appearance of having been amputated 
about the union of its upper and middle third, the surface having subsequently 
healed over in a very perfect manner. No appearance of cicatrization was visible 
except over the ends of the two bones, where the skin was puckered and drawn 
in in an umbilical form. Midway between, and a little in front of these two points, 
was a raised cutaneous tubercle, divided on the surface into five minute nodules, 
on two of which small points of nail could be detected. This projection Dr. 
Simpson stated various reasons for believing to indicate an effort of nature to re- 
place the lost portion of the limb, — he considered it to be in fact a rudimentary 
hand, and a curious illustration of the power of regeneration of even compound 
parts in the embryo and fetus in utero. 

Dr. Simpson showed a great number of casts and drawings of other similar 
cases. The general resemblance of the cases to each other was very remarkable. 
In all, the amputation seemed to have happened at precisely the same situation ; 
in all, the cicatrices over the ends of the two bones were well marked ; and in all, 
there was a more or less marked indication of an attempt of reproduction of the 
lost portion of the member. 

Dr. Simpson also showed, as an illustration of the mechanism or production of 
spontaneous amputations, a child born in the Maternity Hospital recently, whose 
fingers and toes were in several parts semi-amputated by bands of coagulable 
lymph or false membrane — the result of inflammation of the cutaneous surface 
of the fetus. The bands still existed at some points. There were the following 
deformities: — 

In the right hand, the second, third, and fourth fingers were joined together 
laterally, in a somewhat conical mass. The index finger, the longest, ended in a 
transversely furrowed tuberculated mass. To the index was joined the fourth or 
ring finger at its apex, and, filling up the triangular interval between them, lay 
the third finger, having only the remains of one phalanx. The fifth or little finger 
ended abruptly at about the middle of its length, and had an osseous nodule re- 
presenting the second phalanx. On its apex is a small crack, and a long dry fila- 
ment is attached. All the fingers of the left hand presented circukr constrictions 
of inconsiderable depth over their first phalanges. In addition, the fourth or ring 
finger seemed merely to possess a remnant of the second phalanx, and then ab- 
ruptly terminated in a constricted tubercle. The right foot was normally formed. 



1849.] 



Malignant Cholera. 



221 



The great toe of the left foot was almost entirely absent, being represented merely 
by some irregular tubercles of skin. The second toe was supplanted by a soft 
bag of integument. The third and fourth toes had each, in place of their terminal 
phalanges, two constricted tubercles, without vestige of a nail. The fifth or little 
toe was well formed.— Monthly Journ., June 1848. 



MALIGNANT CHOLERA. 

82. Course of Cholera— its rate of progress — its mortality — its preliminary stage. — 
One of the most remarkable facts connected with the Asiatic Cholera is, that, in 
its present progress throughout Europe, it should follow so nearly the course which 
it took in 1830-1. The researches of Dr. Lasegue have shown that this analogy 
not only exists in respect to the time at which the places are visited, but in respect 
to the duration of the disease at each place * The cholera appeared at Tiflis 
on the 5th May, 1830; at Astrachan on the 21st June; and, ascending the Volga, 
it reached the Russian province of Kasan on the 17th of September in the same 
year. In 1847 the cholera made its appearance at Tifiis on the 1st June, at As- 
trachan on the 31st July; and reached Kasan on the 4th October. In 1830. as in 
1847, it took five months to traverse the same district. 

In 1830, taking the course of the Dnieper, it reached Stavropol on the 6th Sep- 
tember; Novo Tscherkosk on the 10th; Taganrog on the 8th October, and Kiev 
on the 8th January, 1831. In 1847, the cholera broke out at Stavropol on the 16th 
July; at Novo Tscherkosk on the 30th ; at Taganrog on the 15th August; and at 
Kiev on the 5th October. Although, as a general rule, those districts, towns, and 
cities which were visited in 1830, have been attacked by the disease on the pre- 
sent occasion, Dr. Lasegue has pointed out one very remarkable exception. In 
1830-1, the disease spread through the provinces on the western frontiers of Rus- 
sia; but in 1847, from some singular and unexplained cause, these provinces 
have escaped; and to this may be perhaps ascribed our immunity from the dis- 
ease up to the present time. 

The ravages of the disease were suspended in the winter of 1830, as well as 
in that of 1847. In both instances Moscow formed the extreme western limit of 
the pestilence; and in the spring of 1831, as well as in that of 1848, the disease 
resumed its course. It appeared in St. Petersburgh on the 25th June, 1831, and 
it broke out in this city, and spread through it with fearful rapidity, on the 
16th June, 1848. It attacked Berlin on the 31st August, 1831, and on the 15th 
August, 1848. It is well known that the disease first appeared in England, at 
Sunderland, on the 26th October, 1831 ; and it will be a remarkable confirmation 
of the analogies hitherto observed in its progress on the continent, if the rumour 
that it has now appeared in one of our seaports on the northeastern coast should 
prove to be well founded. If we are to be guided by .this analogy, the cholera 
may not appear in the metropolis until the ensuing winter. The first cases were 
announced in London on the 13th February, 1832, and they occurred in the im- 
mediate vicinity of the docks. The disease appeared in Paris in the spring of 
1832, and that city, therefore, may escape the visitation until the spring of 1849. 

It is worthy of remark that in 1830-1, as in 1847-8, the cholera has manifested 
itself chiefly in the great lines of intercourse along frequented roads, and the 
banks of navigable rivers, attacking chiefly towns and cities where the population 
was most dense, producing the largest amount of mortality in its first onset, then 
slowly diminishing in severity, and finally disappearing to reappear in a neigh- 
bouring locality. According to Dr. Lasegue, the greatest rapidity with which the 
cholera has spread over any locality has not exceeded a rate of from 250 to 300 
miles a month.. This comparatively slow progress, together with its advance in 
the face of prevailing winds, is very unlike the usual mode of diffusion of a purely 
epidemic disease. 

It was confidently announced a year since, that the cholera, as it then prevailed 
on the continent, had lost much of its severity, and was far less mortal than the 



* U Union Medicate, Sept. 1848. 
No. XXXIII.— Jan., 1849. 15 



222 



Progress of the Medical Sciences. 



disease of 1830-1. This statement, however, is contrary to fact. In comparing 
its fatality in the countries to which its ravages have been hitherto confined, the 
deaths are, even comparatively speaking, more numerous than on the former 
visitation. In the Russian empire alone, between the months of April and Au- 
gust 1848, no less than 505,328 persons were attacked with cholera, and of these 
210,836 died — a mortality of more than forty per cent. The tables published by 
the Sanitary Board of St. Petersburgh show, that in estimating the mortality pro- 
duced by the disease in fourteen of the principal cities of the empire, it appears, 
that in 1847, of 21,295 attacked, 11,361 died; and in 1830-1, of 15,559 attacked, 
9,018 died. The proportion of those attacked to the total population, was about 
the same. Thus, in the Russian empire, the proportion of deaths to the attacks 
was — 

In 1830-1 In 1847 

1 to 1-7 1 to 1-8 

and the proportion of those attacked to the total population was — 

In 1830-1 In 1847 

1 to 19-6 inhabitants. 1 to 19-7 ditto. 

Even in Berlin, where it was alleged that the cholera had appeared in a much 
milder form, in the present invasion, we find that from the 15th August to the 1st 
of September, the attacks were 377, and the deaths 235 — or no less than 64 per 
cent! This great mortality may be ascribed to the severely epidemic form in 
which the disease has prevailed in that city. 

Experience has added one fact of importance in a prophylactic view to our 
knowledge of this terrible pestilence. As a general rule, the Russian practitioners 
have observed, that the suddenness of an attack of cholera is apparent, and not 
real — it is in its severe form, the secondary and intractable stage of a disease 
which, at its commencement, is comparatively mild and tractable; and which, if 
taken in time may be without difficulty arrested by simple remedies. Their ex- 
perience has led them to the conclusion, that diarrhoea is a precursory symptom of 
an attack of Asiatic cholera ; and this diarrhoea may or may not be attended with 
pain in the abdomen. There is very frequently an entire absence of pain — a cir- 
cumstance which leads to the neglect of means for remedying what appears to be 
a temporary disorder, but which may turn out to -be the forerunner of the fatal 
malady. In the diarrhoea preceding cholera, when pain has been noticed, it has 
been simple uneasiness, with a sense of contraction in the bowels. The number 
of evacuations may be from one to six or more daily : they retain in this stage 
their fecal colour and odour, and are in this respect very different from those al- 
vine discharges, which occur in the more advanced stage of the disorder ; for 
these have no fecal odour or colour, and resemble rice-water. This simple diar- 
rhoea may, therefore, be considered to be the commencement of an attack of 
Asiatic cholera, this name being applied only to the last stage of the disease. 

The diarrhccal stage may last only a few hours — two or three days, or even 
longer. If properly treated, the second stage maybe entirely averted — if ne- 
glected, this will commence suddenly and violently with those severe symptoms 
which are commonly the precursors of death. The suddenness of an attack of 
cholera is, therefore, only apparent — when inquiry has been made, the milder 
stage, although in some instances of very short duration, had really existed, but 
was overlooked. These views of the Russian physicians are strongly confirmed 
by the observations made by Dr. Monneret, the French Medical Commissioner at 
Constantinople and Trebizond. We cannot now enter into the question, whether 
cholera does or does not in some instances destroy life without a diarrhoeal stage. 
This is quite foreign to our object, which is that of endeavouring to find out some 
warning symptom of the disease, so that the person attacked may be placed on 
his guard, and induced to seek medical advice without loss of time. Let us ad- 
mit, for the sake of argument, that from 100 cases diarrhcea may not appear in 
14: our remarks are directed to the 86 who suffer from this very common pre- 
monitory symptom. 

It follows, from the preceding observations, ivhen cholera is prevalent in a locality , 
the slightest disturbance of the bowels requires attention. Considering the possi- 
ble risk incurred by neglect, the fact that there is only one evacuation more than 
common, or that the evacuation is more liquid than natural., should receive imme- 



1849.] 



Malignant Cholera. 



223 



diate notice. If the diarrhoea really depend on other causes, and not on cholera, 
no mischief will follow from its arrest by medicine; — if, however, it depend on 
the cholera-poison beginning already to operate on the body — then, by resorting 
to treatment, a life may be saved. It must be remembered that we have no means 
of determining a priori on what the diarrhoea depends ; and, contrary to popular 
belief, it appears that the diarrhoea of cholera is really of a more mild description 
than that which arises from any local cause of irritation in the bowels. — Lond. Med. 
Gaz., Oct. 6, 1848. 

83. New Remedies for 'Epidemic Cholera. — The experience derived from the 
second invasion of Europe by cholera, seems to have led to no important dis- 
coveries in the mode of treating that disease. Three new remedies only have 
been offered with any claims to confidence. The first, the Persian Petroleum, 
which was ushered into notice under the sanction of Mr. Guthrie, was said to 
have been used in Russia with great success. Its fame was, however, but short- 
lived — subsequent trials have not justified any confidence in it. Mr. Robinson 
tried it in Edinburgh, as will be seen by a subsequent article, but its sole power 
seemed to be to allay the vomitings, and for this it was not superior to other 
known articles. 

Chloroform, as might have been anticipated, has been employed, and the ap- 
parent success with which it was used at the Peckham House Asylum, excited 
great hopes that it would prove of the greatest utility. These hopes have not, we 
are sorry to say, been realized. It seems to have the power, solely, of allaying 
the pain and cramps, but to exert no curative influence over the disease. Full 
accounts of the use of the article in the Peckham House Asylum, and also in the 
Cholera Hospital at Edinburgh, will be found in subsequent articles. 

The last remedy we are to notice is the terchloride of carbon. This article is 
said to produce reaction, in the dose of five grains, bur the evidence of its power 
is too vague to enable us to judge what confidence can be reposed in it. 

In the following articles will be found all the information of interest which has 
appeared in ihe late journals respecting the treatment of this epidemic. 

84. Persian Petroleum in Cholera. — Dr. Robertson says that this article, of which 
he employed an undoubtedly genuine specimen, when given in doses of ten or 
twelve minims, immediately after the contents of the stomach have been ejected, 
either with a teaspoonful of tincture of cardamoms, or suspended in mucilage, he 
had frequently found of service in preventing the recurrence of vomiting, and 
believes that when this symptom is troublesome, the remedy is at least as certain 
as opium, acetate of lead, or calomel. In the majority of cases it has (like every 
other drug) failed, and certainly it has no specific action as a cure for cholera. — 
Month. Journ.j Dec. 1848. 

85. Treatment of Cholera by Chloroform in PecJcham House Asylum. — Dr. James 
Hill states that the chloroform, the use of which was first suggested by Mr. Francis 
Ferguson, the assistant-surgeon of the Peckham House Asylum, has been employed 
in ten cases of malignant cholera with perfect success, and has likewise received 
the sanction of Dr. Clutterbuck, the visiting physician, and Mr. Fidler, the visiting 
surgeon of the establishment. 

The disease first broke out there in a malignant form on the 19th inst. (one mild 
case haying appeared two days before) , when four cases occurred, two of which 
proved fatal, the one in seven and the other in eleven hours. On the following 
morning a new case occurred, in a very aggravated form, characterized by inces- 
sant vomiting and cramps, violent purging, universal coldness and blueness of 
skin, and general collapse. 

Seeing that the most approved methods of treatment were of no avail, either in 
this case or in those attacked the previous day (another of whom was fast sinking), 
and that this patient must likewise assuredly sink ere long, unless relief were ob- 
tained, Mr. Ferguson suggested the employment of chloroform by inhalation, 
under the influence of which she was then placed, (in one hour after being at- 
tacked), with the abatement of every bad symptom: the nervous system being 



224 



Progress of the Medical Sciences, 



[Jan. 



immediately tranquillized, the vomiting and cramps ceasing, the purging being 
cheeked, and the heat of the body returning. 

"This success, says Mr. H., encouraged us to persevere; and we have now 
employed it in ten cases of malignant cholera with complete success, six having 
perfectly recovered, and four being convalescent. 

" In two of the fatal cases it was also used, but in them the patients were both 
sinking before the remedy was thought of. 

u In the asylum we have had in all seventeen cases of malignant cholera : of 
whom five have died, eight have recovered, and four remain under treatment, but 
are now convalescent. 

" The following is onr usual mode of treatment: — Place the patient in bed in 
warm blankets; give a glass of brandy in hot water, with sugar, and spice; apply 
friction to the body by means of warm flannels ; and an embrocation composed 
of liniment, saponis comp., liniment, camphorse, comp. tinct. opii, and extract, 
belladonnas; apply to the whole surface of the body bags filled with heated bran ; 
place the patient under the influence of chloroform by inhalation, and keep him 
gently under its effect as long as the bad sympioms recur, (which they frequently 
do on its effect ceasing and his regaining consciousness). Give in the intervals 
small quantities of brandy and water, and thin arrow-root or milk for nourishment, 
aicfng with milk and water, or soda water with a little brandy for drink. Avoid 
everything else in the shape of medicine, and trust to the efforts of nature in rally- 
ing from the poison of the disease. 

" Of course great caution is necessary in administering the chloroform, and in not 
pushing it too far. In some instances the patient will sleep for twenty minutes 
or half an hour — in others, for several hours; and on awaking will again be seized 
with a return of the vomiting and cramps, when the chloroform must again be 
resorted to, and the patient kept in a great measure under its influence till these 
symptoms abate. One of our cases required its use at intervals for twenty-four 
hours. Again, the reaction after its use may be so great as to require gentle blood- 
letting; which occurred in two of our cases, both being persons of full habit of 
body and sanguine temperament, the one a nurse, and the other a male farm ser- 
vant. 

" Should the simple apparatus commonly used in the hospitals for administering 
it not be at hand, a small teaspoonful may be poured upon a towel, and will an- 
swer very well. That which we use is of great purity, and procured chiefly from 
Messrs. Gifford and Linden, chemists, 104, Strand." — Dublin Med. Press, Nov. 8, 
1848. 

86. Treatment of Cholera by Chloroform at the Peckham House Asylum. — By. 
Messrs. Hill and Ferguson. 

Total number of malignant cases - - - 42 ) ^ 
Relapses 6 j 

Recoveries, 33; Deaths, 15. 
Treated by chloroform, as the sheet-anchor — 

Cases - - 37 ) .„ 

Relapses 6 j 4d 

Recoveries, 31; Deaths, 12. 

Two of these, however, were dying before the chloroform was thought of as a 
remedy. 

All of the cases were undoubtedly of confirmed malignant cholera, and, with 
scarcely an exception, presented the whole of the following symptoms — viz., vo- 
miting, purging, cramps, and collapse; while in many the characteristic blueness 
of countenance and extremities was well marked. 

The great object in the treatment is to get the patient under the influence of the 
chloroform before the collapse is extreme, and the system has been drained by 
excessive discharges, in which cases the amendment has appeared to be merely 
temporary. Many of our cases have been struck down lifeless, as it were, from 
the very first, and in such, I fear, no remedy will ever be found of much avail. 

In addition to the above malignant cases, we have had nearly sixty instances 
in which the following premonitory symptoms occurred — namely, nausea, diar- 



1849.] 



Malignant Cholera. 



225 



rhcea, pains in the bowels, shivering, and coldness of the extremities, but which 
for the most part readily yielded to ordinary treatment, although it is not impro- 
bable that many of them would have relapsed into a more severe form unless 
checked at the onset. These, of course, are not taken into account in our statis- 
tics of the disease. — Lancet, Nov. 18. 

87. Chloroform Inhalations in Cholera. By William Robertson, M.D. — Chloro- 
form inhalations, it was not unnatural to suppose, would be found of considerable 
efficiency in at least removing the painful sensations of the patient during an 
attack of cholera. Most marvelous accounts of their efficacy in removing the 
most formidable symptoms of cholera have been published, and most unaccount- 
able it seems to me, that in a large number of experiments undertaken while 
strongly prepossessed in favour of the remedy, conducted with considerable pa- 
tience, and all the precautions conceived necessary to insure success, — conducted, 
moreover, in a public hospital, and before the eyes of many observers of acknow- 
ledged accuracy, — I should have totally failed in achieving similar delightful re- 
sults. Truth compels me to state, that although chloroform has done much for 
the comfort of my cholera patients, it has done nothing for their cure. The cramps 
and urgent vomiting cease under its use, but recur whenever the patient awakes; 
and, although the soporific influence be maintained for hours by repeated inhala- 
tions, the result is still the same. The acts of vomiting and purging cease for a 
time, but the fluids are nevertheless still collecting in the stomach and bowels ; the 
pulse becomes smaller and smaller, till it finally ceases to be felt at the wrist : the 
respiration becomes slower, the temperature of the surface sinks, as in too many 
cases of fatal collapse, and death closes the scene. I confess it seems to me pro- 
bable, that chloroform inhalations, when administered during a profound state of 
collapse, may precipitate the fatal event by diminishing the frequency of the re- 
spiratory movements. While I deny the drug all claim to the title of a specific 
in confirmed cholera, I do not deny its efficacy in removing the earlier and more 
painful symptoms of the disease, nor decry the propriety of using it at any period 
when the cramps are severe. — Month. Journ., Dec. 18 18. 

88. Means of Applying Heat to Cholera Patients. — Dr. William Robertson states 
that at the Cholera Hospital in Surgeon Square, Edinburgh, he has found the fol- 
lowing means more efficacious for restoring warmth to cholera patients than the 
methods usually adopted for that purpose. " A sheet wrung out of warm water 
is applied, as hot as the patient can bear it, over his whole body, including and 
closely embracing the limbs, and leaving no part of the person but the head un- 
covered. Over the sheet several blankets are tightly wrapped, or 'packed,' after 
the fashion of the hydropaths, but without the slightest respect for their pathology, 
or wish to imitate what they can with justice claim as their exclusive practice. 
Between the folds of the blankets, vessels full of warm water are disposed at in- 
tervals. The patient is then placed in a position which enables him to vomit 
over the side of the bed. and is supplied with toast and water, hot or cold, ad libitum. 
The remedy is an ancient one, often revived in modern times, and is to be regarded 
merely as a simple and powerful hot-bath. Whether it acts by restoring the healthy 
functions of the skin, by preventing evaporation, or by conveying fluids into a 
system from which they have been previously drained away, may possibly admit 
of question. It certainly seems to me, when applied in the case of children suf- 
fering from the collapse of cholera, to be a most valuable and rapid mode of re- 
storing the natural temperature. I have seen reaction established in a bad case 
within two hours after the application of the sheet. It is, however, generally 
necessary to continue the use of the remedy for six or eight hours. This practice 
seems less applicable to adults; the extreme restlessness, jactitation, efforts to 
vomit and to procure drink, usually observed in such patients, render it quite im- 
possible to continue the application of the sheet for more than a few minutes at a 
time, without more constant nursing than the utmost vigilance on the part of the 
medical attendants can, in an hospital, ensure. Strong patients commonly suc- 
ceed, ere long, in disengaging their arms, and throwing the bed-clothes off the 
upper part of the trunk, thereby exposing an extensive moist surface to evapora- 
tion, and totally defeating the object which we seek by the use of the sheet to 
attain.' 7 — Month. Journ., Dec. 1848. 



226 



Progress of the Medical Sciences. 



[Jan. 



89. Injection of Saline Fluids into the Veins. By William Robertson, M. D. — 
The injection of a saline fluid into the veins has, by some practitioners, been so 
strongly recommended, and, on theoretical grounds, seems so rational a practice, 
that I have not scrupled to resort to it in eight desperate cases. It has never seemed 
to me a sufficient objection to this practice, that a very large proportion of patients 
subjected to it die; and had I succeeded in saving a single individual of the eight, 
by injecting the veins, I should have thought myself fully justified in repeating the 
experiment. For of these eight cases, not one, according to all human probability, 
had the slightest chance of a prolonged existence, unless it were by the application 
of some remedy equally prompt and energetic in its action. Before the hospital 
in Surgeon Square was opened, the saline injection of the veins was thrice attempted 
in the Royal Infirmary ; in one instance, I believe, with temporary benefit ; but all 
three patients died within a few hours after the performance of the operation. One 
ol these patients, an old woman in the last stage of collapse, fell under my charge, 
and had five pounds of the ordinary saline solution, recommended by the late Dr. 
Mackintosh, injected cautiously, at a temperature of 98°, into the median basilic 
vein. The process lasted about forty minutes ; the patient did not rally in the 
slightest degree, and died in my hands. It was not unreasonable to infer, that the 
sudden death in this case was the immediate consequence of the operation ; yet 
dissection satisfactorily showed that no air had entered the heart or veins. In the 
eight cases treated in Surgeon Square, the solution used consisted of Mnriat. sodse, 
§ss., Bicarb, sodae, 9iv., and Phosph. sodse. ^ss, dissolved in ten pounds of water, 
and then filtered. Care was taken to keep the solution at a temperature of 110° 
to 115°, and all reasonable precautions were adopted in the performance of the 
operation. The instrument used was an ordinary Read's syringe, and it was 
carefully cleaned before and after each injection. If this precaution is not observed, 
a quantity of copper must be injected along with the first portions of the fluid. A 
little difficulty was sometimes experienced in avoiding a certain degree of injec- 
tion of the cellular tissue of the arm. .The best mode of preventing this accident 
is to puncture the vein as in ordinary venesection, without any preliminary dis- 
section, to push the silver tube into the vein gently, until the cross plate rests accu- 
rately upon the skin, and, above all, not to hurry the process of injection. In only 
two of my eight cases was even temporary amendment observed, — all died within 
fourteen hours. The quantity of fluid injected varied from two to five pounds. 
These results have been sufficiently discouraging, and have led me seriously to 
consider if a repetition of the practice is advisable. Cases of the most unpromising 
aspect do occasionally rally, and get well, after a collapse so profound as to leave 
no reasonable hope of recovery. I may instance a young woman named Hutche- 
son, whose case seemed quite desperate, and to admit of no rational remedy but 
injection of the veins. No suitable vein could be found, yet the patient is now quite 
convalescent. Are unexpected recoveries like this more frequent than cures 
effected by the saline injection of the veins in equally desperate circumstances'? 
Till this question be resolved, I think we may still occasionally attempt a cure by 
the operation. — Month. Journ., Dec. 1848. 

90. Directions Relative to the Prevention and Treatment of Cholera, by the Royal 
College of Physicians of London. — The Royal College of Physicians of London, 
feeling that, on the re-appearance of epidemic cholera in England, the public may 
naturally look to them for advice and guidance, have deemed it proper to appoint 
a cholera committee, composed of physicians who hold important offices in the 
metropolitan hospitals, or who had extensive experience of the disease at its last 
visitation, to consider what measures it is expedient to adopt, with a view of pre- 
venting the spread of the disease, and of otherwise mitigating its evils. 

The committee thus formed have, in compliance with the wish of the College, 
drawn up the following remarks and instructions, for the information of the 
public : — 

1st. Cholera appears to have been very rarely communicated by personal inter- 
course ; and all attempts to stay its progress by cordons or quarantine have failed. 
From these circumstances, the Committee, without expressing any positive opi- 
nion with respect to its contagious or non-contagious nature, agree in drawing this 
practical conclusion; that in a district where cholera prevails, no appreciable in- 



1849.] 



Malignant Cholera. 



227 



crease of danger is incurred by ministering to persons affected with it; and no 
safety afforded to the community by the isolation of the sick. 

2d. The disease has almost invariably been most destructive in the dampest 
and filthiest parts of the towns it has visited. The Committee would therefore 
urge on the public authorities the propriety of taking immediate steps to improve 
the state of sewers and drains; — to cover those which are open: — and to remove 
all collections of decaying vegetable and animal matter from the vicinity of dwell- 
ings. They would also impress on individuals, especially of the poorer classes, 
the great importance of well-airing their rooms ; and of cleanliness in both their 
dwellings and persons. 

3d. A state of debility or exhaustion, however produced, increases the liability 
to cholera. The Committee, therefore recommend all persons, during its preva- 
lence, to live in the manner they have hitherto found most conducive to their 
health; avoiding intemperance of all kinds, and especially the intemperate use of 
ardent spirits and other intoxicating liquors. A sufficiency of nourishing food; 
warm clothing, and speedy change of damp garments; regular and sufficient 
sleep; and avoidance of excessive fatigue, of long fasting, and of exposure to wet 
and cold, more particularly at night, are important means of promoting or main- 
taining good health, and thereby afford protection against the cholera. 

The Committee do not recommend that the public should abstain from the 
moderate use of well-cooked green vegetables, and of ripe or preserved fruits. 
A certain proportion of these articles of diet is, with most persons, necessary for 
the maintenance of health; and there is reason to fear, that if they be generally 
abstained from, now that the potato-crop has in a great measure failed, many 
persons, especially amongst the poor in large towns, will fall into that ill condition, 
which in its highest degree is known as scurvy, and that they will in consequence 
be the readier victims of cholera. The Committee likewise think it not advisable 
to prohibit the use of pork or bacon; or of salted, dried, or smoked meat or fish; 
which have not been proved to exert any direct influence in causing this disease. 
Nothing promotes the spread of epidemic diseases so much as want of nourish- 
ment; and the poor will necessarily suffer this want, if they are led to abstain 
from those articles of food on which, from their comparative cheapness, they 
mainly depend for subsistence. 

On the whole, the Committee advise persons living in districts in which cholera 
prevails, to adhere to that plan of diet which they have generally found to agree 
with them; avoiding merely such articles of food as experience may have taught 
them to be likely to disorder the stomach and bowels. 

4th. The Committee are unable to recommend a uniform plan of treatment to 
be adopted by the public in all cases of looseness of the bowels, supposed to be 
premonitory of cholera. It is, doubtless, very important that such aliments should 
be promptly attended to ; but since they may arise from various causes, of which 
a medical man can alone judge, the Committee deem it safer that persons affected 
with them should apply at once for medical assistance, than that they should in- 
discriminately use, of their own accord, or on the suggestion of unprofessional 
persons, powerful medicines, in large and frequently repeated doses. Should the 
looseness of the bowels be attended with feelings of great exhaustion and chilliness, 
the person should, of course, be placed in a warm bed, and the usual means of 
restoring warmth to the body be assiduously employed, until professional advice 
can be obtained. 

5th. Tn order that the poor may have the means of obtaining such assistance 
promptly, the Committee recommend that the proper authorities should at once 
establish dispensaries in those parts of the town which are remote from the exist- 
ing medical institutions; and that they should also take steps to provide distinct 
cholera hospitals, which it will require some time to organize, and which they 
believe will be found to be absolutely necessary, should the epidemic prevail in 
this metropolis with a severity at all approaching that which it manifested on its 
first appearance in England. The Committee wish it to be clearly understood, 
that they do not recommend the establishment of such cholera hospitals, on the 
ground of effecting the separation of the sick from the healthy, and of thus pre- 
venting the spread of the disease; but solely in order that, should the epidemic 
prove severe, proper attendance and prompt treatment may be ensured for the 



228 



Progress of the Medical Sciences. 



[Jan. 



sufferers from cholera among the poorest and most destitute class. The existing 
hospitals, even if the authorities should consent to the admission of persons ill of 
cholera, could not furnish the requisite accommodation, unless they were shut 
against persons labouring under other severe diseases — a measure which, at the 
approach of winter especially, would add much to the distress of the poor. 

6th. In conclusion, the Committee would urge on the rich, who have compara- 
tively little to fear for themselves, the great duty of generously and actively mi- 
nistering to the relief of the poor, while the epidemic prevails; bearing in mind 
that fuel, and warm clothing, and sufficient nourishment, are powerful safeguards 
against the disease. 

They deem it most desirable that the parish authorities should at once improve 
the diet, and increase the comforts, of the poor under their charge; and that the 
wealthy should form societies for the supply of food, clothing, and fuel, to those 
who, though not paupers, still need charitable assistance in the present emergency. 

Such measures, which it is the duty of those possessed of power and wealth to 
adopt, would, the Committee believe, it liberally carried out, deprive the cholera 
of half its victims. 

John Ayrton Paris, President. 
Francis Hawkins, Registrar. 

College of Physicians, Oct. 28, 1848. 

Prov. Med. and Surg. Journal, Nov. 15. 



MEDICAL JURISPRUDENCE AND TOXICOLOGY. 

91. Researches on the Principal Metallic Poisons, and Mode of Ascertaining their 
Presence. By M. Abrue. (Read to the French Academy, &c.) — It often happens 
that persons called upon to make toxicological examinations of substances en- 
trusted to their care, regret the absence of a positive and unique method to serve 
as a guide when they are entirely without any indication as to the direction which 
should be given to their research. 

Indeed, the treatises on toxicology which, in other respects, afford so much 
valuable information on the research after poisons, often leave the reader in a 
state of the most serious embarrassment, in proposing to him for each poison 
various processes, differing very much in value, and of a very dissimilar kind. 

Hence arises a grave inconvenience. The investigator who wishes to ascer- 
tain with accuracy the presence of a poison in the suspected matter under investi- 
gation, finds it necessary to make so many experiments before he can in any way 
arrive at the probable nature of the poison for which he is searching. 

This void we here endeavoured to fill as far as concerns the principal metallic 
poisons, and to bring the medico-chemical operations to the point of a single pro- 
blem of analytical chemistry: — One or more metals being given in the coritents of an 
organic matter to determine their nature. 

To arrive at a solution of this important problem, we have passed successively 
in review the different well-known methods which up to the present time have 
been proposed for the special research of each metal. 

Struck with the distinctness of the results obtained in the research after antimony, 
by the process of M. Millon. which consists, as is well known, in destroying the 
organic matter by the combined action of hydrochloric acid and chlorate of potash, 
we have conceived the idea of drawing up the basis of a general method, and 
have arrived at a modification of this process in such a mariner, as not only to 
extend it to the research after all the principal poisons, but still more completely 
to disembarrass us of the organic matter. 

This method comprehends the compounds of the following metals: — 

Arsenic I Mercury Tin 

Copper Zinc 
Antimony Lead Silver. 

The operation will be as follows: — 

Analysis of the solid matters found in the stomach, the matters vomited, and of the 



1849.] Medical Jurisprudence and Toxicology. 



229 



stools, the tissues of the gastro-intestinal canal, the liver, and other organs, or any other 
suspected solid matter, the blood, the urine, and other organic liquids, previously concen- 
trated at a gentle heat. 

The investigator should first attentively examine by the naked eye, or better 
still, by a glass, the substances passed in the vomits and the stools, the matters 
found in the digestive canal, and the mucous surface of the same canal. He may 
thus in some cases furnish himself with valuable indications, which will put him 
in the way of research, and it is possible, as is sometimes the case, that he may 
find in the digestive canal, and particularly in the folds of the mucous membrane, 
solid particles of the poisonous substance. 

In this last case, he must carefully remove, by means of a small pencil, the 
particles of poison, and hasten to examine them by the ordinary methods; but 
supposing that no important indication results from this physical examination, he 
must proceed as follows in the research of the poisons comprised in the above 
table. 

With very clean scissors dividing the suspected matter into very small portions, 
take a given weight, which should never be less than two hundred grammes 
(about seven ozs.), and introduce it into a glass flask, with one half its weight of 
pure and smoking hydrochloric acid. At the neck of the flask is to be adapted a 
cork, perforated with two holes, of which the one is destined to receive a tube of 
fifty-five to sixty centimetres (twenty inches) in length, and one centimetre (three- 
eighths of an inch) in interior diameter, dipping an inch in hydrochloric acid. 
From the other opening arises a tube bent back at a right angle, of which the 
second vertical branch plunges through a cork into distilled water contained in a 
receiver. The cork of this is furnished with a second hole destined to receive a 
straight tube which will not plunge into water. 

Things being thus arranged, the flask is placed on a sand-bath, and the receiver 
in cold water changed from time to time; the sand-bath is maintained at a tem- 
perature near the boiling point of the liquid, without reaching that point, during 
at least four hours, agitating the contents of the flask from time to time. 

The fragments of organic matter gradually dissolve in the hydrochloric acid, 
and at length form with it a dense, homogeneous, and more or less dark liquid. 
Remove the sand-bath, and place the flask on the naked fire, and boil the liquid 
during two or three minutes. This done, commence to introduce by little and 
little crystals of chlorate of potash by the larger tube (taking care to agitate the 
flask continually), until about sixteen to eighteen grammes have been added for 
each one hundred grammes of the suspected matter under examination. 

A vivid reaction and abundant disengagement of chlorine gas takes place; the 
liquid gradually clears, and at last becomes completely limpid and of a yellow 
colour, the intensity of which, varying much in its shades of colour, appears to 
depend especially on the great excess of chlorine which remains in solution, and 
not only the liquid in the flask, but the water in the receiver exhibit in a high 
degree the characteristic odour of chlorine. Small fragments of carbonaceous 
matter and of a resinoid substance float on the surface of the liquid in the flask, 
which are less abundant in researches on the blood, and is very abundant when 
the operations are conducted on the liver and other parenchymatous organs. 

Allow the apparatus to cool, filter the liqnor in the flask and mix with the water 
in the receiver, and that which has served for several washings, the residuum 
which remains in the filter. Pass a current of well washed sulphuretted hydro- 
gen through the liquid for some time, and allow it to remain until the next day in 
a closed bottle. In every case there will be formed a precipitate more or less 
abundant in which should be sought for all the metals comprised in our table, 
except silver and zinc. The precipitate may nevertheless contain only sulphur 
and a small quantity of organic matter, which may be got rid of in the following 
manner: — Throw the precipitate on a filter without folds, wash with distilled 
water, and put it into a small flask with its weight of pure and fuming hydrochlo- 
ric acid ; boil, and add a few crystals of chlorate of potash. When the reaction 
is over add a small quantity of distilled water, and apply heat with much precau- 
tion to drive off all the free chlorine. Filter again, and thus a limpid, scarcely 
yellow-coloured liquid will be obtained. It is in this liquid that arsenic, antimony, 
mercury, copper, lead, and tin is to be found, if the suspected matter contain 



230 



Progress of the Medical Sciences. 



[Jan. 



either of these substances. As to the zinc, as it is not precipitable by sulphuretted 
hydrogen from an acid liquor, this metal must be sought for in the liquid obtained 
by filtration after the action of sulphuretted hydrogen. As silver can only be found 
in an insoluble state, it must be sought for in the residue of the first filtration. 

After having thus described our process, we pass to the examination of the most 
sensible methods for ascertaining the presence of the different metals contained in 
the above table, endeavouring to avoid all the causes of error which are likely to 
arise. In the liquid obtained in the last place, we search simultaneously for 
arsenic and antimony by means of Marsh's apparatus, as modified by the Aca- 
demy of Sciences: we then pass to the research after mercury, copper, lead, and 
tin, in the liquid contained in the apparatus, after having dissolved in aqua regia 
all that is deposited at the bottom of the bottle. As for zinc and silver, the first 
must be sought for in the liquid obtained by filtration after treatment with sulphur- 
etted hydrogen; and the second in the residue of the first filtration. We have 
often operated on two milligrammes (l-38th of a grain) mixed with considerable 
quantities of animal matters. — Dublin Med. Press, Oct. 18, from Pharmaceutical 
Journal. 

92. Case of Poisoning by Arsenic, in which the symptoms were unusually delayed. — 
Walter Clegg, Esq., reports {Lancet, Nov. 4, 1848) the following remarkable 
case of this character. 

" On Sunday, August 27th, at five o'clock in the afternoon, a woman requested 
me to visit her niece, who had, about noon, taken a teaspoonful of white arsenic. 
I attended, and found a heavy, stupid looking girl sitting in her chair, more asleep 
than awake. On rousing her, she reeled about the room as if intoxicated ; indeed, 
I suspected poisoning by some narcotic. But she acknowledged having swallowed 
£ white mercury,' and a paper packet was brought to me, from which she had 
taken the poison, containing about ten grains of a white powder. By means of 
my pocket-lens, I immediately recognized this powder to be arsenious acid. She 
vomited once after dinner, but there were no further symptoms until half an hour 
before she died — that is, at noon the following day. 

£: She had no sickness, no pain, no acrid eructations, no burning taste in the 
mouth; her face was very pale, and she was faint and giddy. The sulphate of 
zinc, with mucilaginous drinks, soon produced profuse vomiting, and this was 
kept up for half an hour. Then another medical man arrived with a jar of the 
hydrated peroxide of iron; and having some pressing professional engagements, 
I left her with my friend, who administered large doses of the antidote. 

" At nine o'clock at night we visited her together. She had experienced no 
pain ; no unpleasant symptom whatever; she was disposed to sleep quietly. At 
ten o'clock the next morning the patient's aunt came to say that her niece was 
quite well, { might she go a gleaning'?' Up to half past eleven o'clock she con- 
tinued more than ordinarily cheerful, and was busied in preparing the family 
dinner. At half past eleven o'clock she suddenly complained of an excruciating 
pain in the body, with excessive prostration of strength. She went to her bed- 
room to lie down, and at twelve o'clock was found dead, kneeling by the bed- 
side. Thus she died in about eighteen hours after taking the poison, and within 
half an hour after the first decided symptom of poisoning was manifested. 

" Autopsy, forty-eight hours afterwards. — The stomach contained half a pint of a 
thin, dirty green fluid ; the mucous coat was much corrugated, having a fungoid 
appearance, very soft, and so fragile that a touch of the finger tore it away. 
Three or four large reddish-brown patches were observed, and these extended 
into the intestine considerably beyond the duodenum. The peritonseal coats of 
the stomach and bowels were not inflamed ; the lungs and the heart were healthy ; 
the head was not inspected. 

" It only remains for me to add that the matter vomited, and the fluids in the 
stomach and intestines, contained abundant evidence of the presence of arsenic. 
Minute fragments of a white powder were seen adhering to the mucous coat of 
the stomach, and these, by the ordinary tests, were proved most satisfactorily to 
be arsenious acid. 

u Explanation (?) — The lower classes in Lincolnshire are very much addicted to 
the use of opium and laudanum. I have known women with three shillings a 



1849.] 



Medical Jurisprudence and Toxicology. 



231 



week from the parish spend half-a-crown in the purchase of opium. I hare rea- 
son to believe that this girl was an opium-eater. Did one poison mask the evi- 
dences of the other? Did the opium suppress the horrible agonies of arsenical 
poisoning, thus modifying the symptoms, whilst it had no power to interrupt the 
effects of the deadly drug?'" 5 

93. Poisoning with Chloride of Zinc— Suggestion of an Antidote. — Dr. Thomas 
Stratton, 'Surgeon R.N., relates in the Edinburgh Bled, and Surg. Journ. (Oct. 
1848) two cases of poisoning with chloride of zinc. In both cases a wineglass- 
ful of a solution was swallowed, containing in one case about twelve grains of 
the salt, and in the other about two hundred grains. In the latter case burning 
pain in the gullet, burning and griping pain in the stomach, great nausea, and 
sense of coldness, were instantly felt. Vomiting followed in a few minutes. 
Dr. S. saw this patient twenty minutes after the accident, and instantly made a 
strong solution of home-made brownish soap, of which he made the patient swal- 
low, at intervals, three or four pints. Afterwards olive oil was given, and the 
patient recovered. The other case was not seen by any medical man, but it also 
terminated favourably. Dr. S. suggests either soap or carbonate of soda or of 
potash, as an antidote to chloride of zinc, and relates some experiments which he 
has tried, and which seem to justify confidence in this suggestion. 

94. Antidote to Strychnia. — Dr. Isaac Pidduck states (Lancet, Nov. 1848) that 
camphor is an effectual antidote to strychnia. The fourth of a grain of strychnia 
(instead of the sixteenth, which had been prescribed for neuralgic pains) was 
taken by a weakly man. His muscles were convulsed with tetanic spasms. Five 
grains of camphor were dissolved in almond emulsion, and almost immediately 
after taking this dose the spasms ceased. 

95. Child born betwixt the end of the sixth and middle of the seventh month and 
brought up. — Rcbert Annan has communicated to the Medical Times (June 17, 
1848) a remarkable case of this character. The subject of it was a woman 38 
years of age, the mother of six children, the youngest being under two years, 
who found herself pregnant, dating from the beginning or middle of the month of 
November, 1847. She was of middle stature, and had been subject to occasional 
attacks of dyspnoea, but otherwise was in good health. In the end of December 
a small, apparently glandular, tumour appeared near to the right side of the um- 
bilicus, which gradually enlarged to nearly four inches in diameter, and suppu- 
rated. This was discharged by the knife on the 24th of February, without pain, 
the patient being put under the influence of chloroform, for which she expressed 
herself in grateful terms. A second and a third tumour, with nearly similar re- 
sults, though the third was not opened by the knife, had the effect of reducing 
Mrs. R. to a state of great emaciation. 

On the 5th of April the pains of labour came on rather unexpectedly, and in 
less than two hours she gave birth to a female child, which, on his arrival, Dr. A. 
found very carefully wrapped up and placed so as to receive the gentle warmth 
of a fire, Unloosening the cloths to enable him properly to tie the cord, which 
had been hastily cut through and tied about six inches from the navel, he found a 
tiny infant, the proportions of which he did not think it proper then to take time to 
ascertain. As it was not expected to survive long it was placed on a cushion in 
an easy chair, so as to be sheltered from draughts of air, and at the same time so 
as to receive benefit from the fire, being previously wrapped up in folds of cotton 
wool and covered over with flannel. An earthenware bottle, filled with warm 
water, which had been pretty constantly continued, was placed behind the cushion. 
To attempt otherwise to dress the infant was never once thought of. This was 
about ten A. M, As the infant showed more signs of vitality, the lips and mouth 
were gently moistened with a mixture of one part of cream, three parts of warm 
water, and sweetened with sugar. At first it was not observed to swallow, but in 
the evening, when Mr. A. returned, there could be little doubt that this had been the 
case from the minute quantities of the mixture, given from time to time, not hav- 
ing been rejected. On the following day, to this mixture from three to four drops 
of sherry wine were added, and continued to be used as yesterday. On the third 



232 



Progress of the Medical Sciences. 



[Jan. 



day the deglutition was very perceptible. Of this advantage was taken, and un- 
der the eye of a most careful female relative from three to four drops of the wine 
were given during every six hours, in as much of the mixture as the infant was 
found able to swallow. 

On the seventh day the child was weighed and found, including a small flannel 
roller, to be twenty-four ounces. The roller was under one ounce in weight. At 
this period the length of the child was not taken, but was supposed to be from 
twelve to thirteen inches. As the feelings of the mother were most acute, and as, 
indeed, she was considered to be in a dying state, and as it was not expected that 
the infant could suck, an occasional wet-nurse was not got till the ninth day; the 
other nourishment being supplemented nearly as above. At first the nurse merely 
milked a proportion into the mouth, but in less than eight days it was found that 
the child could draw a little, which gradually improved. Occasionally a small 
portion of magnesia usta or castor oil was given, so as to ensure regularity in the 
bowels. About the end of the third week very fine oatmeal gruel, sweetened 
with sugar, was alternated with the cream and water, the quantity of wine being 
gradually increased; and latterly the quantity given during twenty-four hours has 
been from one to one and a half teaspoonful. 

On 16th of May the child was baptized by the Rev. James Thornton, of Milna- 
thort, and was then observed to cry lustily for an infant of such tiny proportions. 
When six weeks and one day old, the weight was accurately ascertained to be 
thirty-nine, ounces; the length, as nearly as a tape applied to the child would en- 
able, showed sixteen and a half inches; and on the 30th of May the weight was 
forty three ounces, having gained four ounces since last weighing. At the last 
period the circumference, by the forehead and occiput, was barely eleven and a 
half inches. 

During the last four weeks the child has been regularly bathed in water, at first 
tepid, but latterly of the temperature of from 65° to 70° of Fahrenheit; and occa- 
sionally, according to the testimony of the very careful female relative, who has 
hitherto so creditably and successfully superintended the nursing, sometimes con- 
siderably lower, and the infant is described as uniformly enlivened and strength- 
ened after the bath. The stomach, it is remarkable, has never once given way ; 
and this must be solely attributed to the extreme care observed in regulating the 
proportions of nourishment, whether by the breast or by the spoon ; and it has 
been remarked that the little creature seems uncommonly happy after her doses 
of wine and gruel. When lifted for necessary purposes, she does not fail to tes- 
tify by her crying the sense she entertains of the annoyance. 

Of the exact period of utero gestation when the infant was born it is not, per- 
haps, possible to speak with absolute certainty; but, taking the whole circum- 
stances together, it does not seem unreasonable, Mr. A. thinks, to fix the period 
as somewhere betwixt the end of the sixth and middle of the seventh month; and 
certainly interesting, more especially in a practical point of view. 



MISCELLANEOUS. 

96. Remarks on Endnsmose. By Ph. Jolly. — This paper enters into a very full 
consideration of the whole subject of endosmose, and commences with a criticism 
of the methods hitherto employed for its measurement, in which the author shows 
that the indications of Dutrochet's Endosmometer are imperfect, and liable to be 
affected by a variety of different errors. In order to avoid these, the author has 
contrived anew method of measuring the amount of endosmose. For this purpose 
he employs a small tube from about three-fourths of an inch to an inch in diame- 
ter, over the one end of which a piece of pig's bladder is tightly tied. The bladder 
is then introduced for some time into spirit of wine, by which treatment it is 
enabled to resist putrefaction for a longer time than it does when unprepared. 
The substance whose diffusion is to be measured, is then brought into the tube 
either in a dry state or in solution, in a known quantity of water, the whole is then 
weighed, and the covered end of the tube inserted about a line under the surface 
of water, in a vessel containing about four pints; the water in which is frequently 



1849.] 



Miscellaneous. 



233 



changed daring the course of the experiment. The tube is then weighed at defi- 
nite intervals, and the weight is found to increase, at first rapidly, and afterwards 
more and more slowly, until at length, in place of increasing, a slight diminution 
begins to make its appearance. The experiment is then at an end : the whole of 
the substance introduced into the tube has disappeared, and nothing but water 
remains. The small diminution noticed at the end still continues, and is proved 
by the author to depend upon evaporation from the surface, the amount of which 
is determined in each experiment by the loss of weight in a tube of exactly simi- 
lar form containing water only. The experiments have shown that this complete 
diffusion of different substances takes place in very different time, the gain in 
weight being with some at an end in a few hours, while with others it goes on 
increasing during several days. It is further proved that the weight of water 
which, so to speak, replaces the different substances is constant, especially if the 
same piece of bladder has been employed, whether the substance has been em- 
ployed in the dry state or in solution in different amounts of water. The quantity 
of w T ater which replaces a unit of the diffused substance, the author calls the en- 
dosmotic equivalent, and the following table contains the results of his experi- 
ments. The number placed before each, refers to the piece of bladder employed 
in the experiment. 





Endosmotic 






Endosmotic 




Equivalent. 






Equivalent. 


1. Common Salt 


4316 


5. 


Sulphate of Magnesia 


11-503 


1. « 


4-58 


6. 


ic _ 


11-802 


2. " 


3991 


6. 


Sulphate of Copper - 


9-564 


2. " 


3-820 


9. 


Bisulphate of Potash - 


2-345 


10. " 


4 352 


3. 


Sulphuric Acid - 


0-391 


11. « 


4-092 


5. 


a 


0-308 


5. Sulphate of Soda - 
7. " 


12-44 


7. 


Hydrate of Potass 


200 09 


12 023 


1. 


u _ 


231-4 


7. " 


11033 


6. 


Alcohol 


4-140 


6. " 


11-066 


8. 




4-132 


1. « 


11 581 


4. 


u _ 


4-336 


1. Sulphate of Potass 


11-42 


6. 


Sugar - - 


7-250 


2. " 


12 65 


7. 


a 


7-064 


4. " 


12-76 


5. 


Gum 


11-79(1) 



The author also gives a series of experiments from which he draws the conclu- 
sion, that the quantity of any substance passing through a membrane in a unit of 
time is proportional to the density of the fluid. Some observations are also made 
which tend to show that the endosmotic equivalent increases with the tempera- 
ture, at least this is generally the case, though common salt appears to be an ex- 
ception to the rule. The paper concludes with a discussion of the physical cause 
of endosmose, for which we refer our readers to the original. — Monthly Retrospect, 
Sept. 1848, from Henle unci Pfeufefs Zeitschrift fur Rationelle Medizin, Vol. 7. 

97. State of Medical Education in Turkey. — [We are indebted to a medical gen- 
tleman, at present residing in Constantinople, for the following details. They 
point to the existence of a state of matters of which very imperfect accounts have 
as yet reached this country; and such as, undoubtedly, is at once the proof and 
the earnest of a new era in the history of civilization having begun in the East.] 

{l Military hospitals, on a large scale, are either built or a-building in every 
quarter of the Turkish empire. There are about one thousand European sur- 
geons attached to the different regiments, two hundred of whom are Jews. The 
chief professor of the Medical College, Dr. Spitzer, is a Jew. He is also one of 
the physicians in ordinary to the Sultan. By him I was introduced to H. E. the 
Hakim Bashy Ismael Effendi, the chief physician of the Ottoman empire, who 
kindly permitted me to visit the different lecture-rooms in the Medical College. 
It is certainly in a very flourishing condition, considering that it has been in ex- 
istence only eleven years. The pupils are brought, by order of the Sultan, from 
all departments of the empire, and are lodged, fed, clothed, and educated, at the 
expense of the government. When qualified as physicians and surgeons, they 



234 



Progress of the Medical Sciences, 



[Jan. 



receive appointments in the array and navy, with salaries of £200 or £300, and 
upwards, according to rank, without distinction of Jew or Gentile. Until lately, 
however, there were no Jews in this college: not that the government excluded 
them, on the contrary, they were invited; but that people, who have been scat- 
tered amongst all nations, yet amalgamated with none, would not send their sons 
to this medical establishment, even although the most flattering prospects of edu- 
cation and worldly advancement were held out to them. But the government 
condescended to smooth all the difficulties which stood in the way of the im- 
provement of this section of its subjects. Through its agents, it held interviews 
on the question of conscientious scruples with the chief Jewish Rabbis; and the 
result was, not only the guaranteeing liberty of conscience to the Jews who 
should enter the Medical School, but the assigning to them a distinct portion of 
the college, so that they might live separate from the Gentiles, the appointment 
of a superintendent of their own persuasion, to see that their religious duties and 
services should be strictly observed — also a shocket, or butcher, of their own ; 
and, in short, every arrangement was made to prevent their being constrained to 
do anything contrary to their conscience. In the language of last year's report of 
the college authorities, — ' Toutes les difficultes ont ete aplanies, et le Gouverne- 
ment n 7 a recule aucune sacrifice pour exercer aussi son influence civilisatrice sur 
cette partie des sujets de PEmpire.' The Sultan lately visited the college, and 
presided at the examination of the candidates for the medical degree. When 
the pupils are first introduced to the college, they are, for the most part, raw, 
ignorant, and uncivilized. They are at first taught Turkish, afterwards the Arabic 
and French languages; next geography, history, arithmetic, and other elementary 
branches of education, including natural history. They have already a very tole- 
rable museum of natural objects, well preserved and well arranged. A small 
botanic garden is also attached to the college. After undergoing a thorough ele- 
mentary education, the pupils enter their medical course, comprising lectures on 
anatomy, physiology, chemistry, materia medica, practice of physic, surgery, and 
midwifery. The only room I did not see was the dissecting-room; it was closed 
at the time for want of subjects, which it is difficult to procure in a country where 
so much prejudice against dissection exists, and even against touching a dead 
body. I was shown into the grand examination room, fitted up with a great 
throne of state for the Sultan, who presides at the yearly examination of the 
candidates for the medical degree. There are also a dispensary and hospital 
attached to the college. The hospital is divided into medical and surgical wards, 
and a special ward is set apart for diseases of the eye. Dr. Spitzer delivers 
clinical lectures in the hospital, which he kindly invited me to attend." — Constan- 
tinople. March, 1848.— Monthly Journ., Sept. 1848. 



1849.] 



235 



AMERICAN INTELLIGENCE. 



ORIGINAL COMMUNICATIONS. 

Cod-Liver Oil in Phthisis. By J. Young, M. D., of Chester. (Com- 
municated in a letter to the Editor.) 

The following case is thought to be not devoid of interest. It shows 
that, in the article used, we have an addition to our resources in the treat- 
ment of consumption, which promises more success than any, or all others, 
in some cases. Certain it is, that the case about to be detailed was an 
unpromising one, and the oleum jecoris aselli was the only, or the first 
article that produced the least check to the onward progress of the dire 
invader. 

Mrs. K., of your city, a widow lady, of a consumptive family, aged 
about forty-four years, visited me last May for advice. She had had a 
cough for fifteen, or more, months, gradually increasing in violence, for 
which she had tried a great variety of remedies, with but little or no 
benefit. She had had various medical prescriptions, and had been pre- 
vailed on to try homoeopathy. She had tried many of the quack remedies, 
such as syrup of wild cherry, Jayne's expectorant, the syrup of tar and 
naphtha, &c, but none of them had been of any service. Her appearance 
was pale and haggard ; her walk exceedingly slow; and bowed forward. 
She had profuse expectoration; exhausting night sweats ; was very "short 
breathed," and coughed, on using a little exercise, almost incessantly, 
with occasional hard " spells" that almost exhausted her ; her appetite was 
variable, and her stomach dyspeptic; her pulse was 110; tongue covered 
with a white fur : respiration from thirty-five to forty in a minute. Aus- 
cultation revealed, under the scapular end of the left clavicle, strongly 
marked bronchophony, and also into the interscapular space the same, though 
less strongly ; in the axilla, pectoriloquy, with a strong gurgling rattle, ex- 
tending over a space of two or two and a half inches, square. Below this 
zone was another, two or more inches in depth, with no vesicular murmur, 
but instead, a slight mucous rattle, particularly when she coughed ; below 
this the respiration was clear, as it was for some space under the sternal 
portion of the clavicle. The right lung was sound. 

Under this state of affairs I thought it almost useless to prescribe any- 
thing. There was, however, one encouraging symptom, she menstruated 
regularly, and while this is the case, I always entertain some hope, no 
matter how unpromising other things may be. I first truncated a portion 
of the uvula, as it was much elongated. This had the effect of relieving, 
at once, the strangling spells of cough. She was requested to take Hasting's 
wood naphtha, commencing with twenty drops three times a day, in simple 
syrup, with five drops of McMunn's elixir in each. This was gradually 
increased, till she took forty-five drops three times a day. In five weeks 
she was not benefitted in the smallest degree, while her strength had dete- 
riorated materially. She now, successively, tried every variety of cough 
mixtures, comprising the terebinthinate and balsamic preparations, but all 



236 



American Intelligence. 



[Jan. 



were of no benefit. Her menstrual period went by in June, without any 
show. By the last of July, her strength was so far gone, and her symptoms 
progressing so rapidly, that she gave up her house in the city, and came 
to Chester, for the benefit of country air, and to escape from the cares of 
housekeeping. 

Her situation at that time was, extreme emaciation; the eyes sunk 
and dark under them; complexion sallow; pulse 120; stomach rejects 
almost everything; no appetite for anything; coughs almost half the time; 
night-sweats ; orthopncea, so that she cannot lie below an angle of forty-five 
degrees; sleeps but little; has chills and fever sometimes every day ; cir- 
cumscribed spots in the cheeks, with burning of hands and feet; so weak 
she " can't walk fifty yards ;" unable to get up stairs without assistance, or 
climbing by the banisters, and stopping every two or three steps ; she has 
become round shouldered and stooping. 

The stethoscopic signs are, in the axilla, extremely loud tracheal, or 
cavernous sounds, with a loud gurgling ratile when she coughs, or endea- 
vours to inspire deeply ; pectoriloquy quite distinct; anterior to this is mucous 
rattle, with bronchophony ; posteriorly the same, but less loud. In the por- 
tion immediately under this, there was more of a crepitating mucous rale 
than when examined previously, and slight bronchophony, the remaining 
portions unaffected, or but slightly so. The expectoration at times is most 
profuse, particularly if by means of opiates the cough is quieted partially, 
for a few hours ; is mostly yellowish, heavy, and sinks in water as would 
lead. Occasionally, however, for a day at a time, it consists mainly of 
greenish-yellow matter, streaked with blood, with considerable froth, or 
mucus, and so offensive to the taste and smell, as to occasion emesis. 

I was completely at the end of my resources, when I received the July 
number of vour journal. I there found two or three cases of consumption, 
by Dr. Bennett, treated with the cod-liver oil. I at once determined to 
try it, as something new, but with little hopes of finding any good come of 
it.' It was procured, but such was the irritability of the stomach, that for 
more than a week its use was not commenced, during which neutral mix- 
ture and naphtha were again used, with the effect of quieting it. She 
commenced it the 20th of August; a dessertspoonful three times a day was 
taken in froth of porter. It rested easily and lightly ; in a few days it was 
increased to a tablespoonful three times a day ; and finding this to have no 
unpleasant effect on the stomach, in a few days more it was increased to 
four tablespoonfuls a day. This quantity was not exceeded. In about 
two weeks she found an evident improvement in her appetite ; in two 
weeks more she found a diminution of her fevers and night-sweats, nor 
did she require so much paregoric to make her cough supportable. She 
had had a constant blister alternated between the shoulders, and on the 
scapular portion of the thorax, which she had neglected re-applying for 
some days, and on the 25th of September she had a severe attack of pleu- 
ritic pain, for which I was summoned in haste to see her. The blister was 
at once applied, and removed the pain, and there was no more return of it. 

At this time, when she was on the use of the fourth pint of oil, the loud 
cavernous sound in the axilla was more tracheal than formerly ; pectoriloquy 
was less distinct, and the gurgling rattle was much diminished ; bronchophony 
still well marked in the same situations as formerly. 

The oil was persevered with, a tablespoonful four times a day. At the 
end of October there was a great amelioration of all the symptoms ; the 
ni^ht-sweats had, in a great measure, disappeared ; the chills and fevers 



1849.] 



Original Communications. 



237 



were gone ; the dyspeptic symptoms all gone, and she had a uniformly good 
appetite. She was ordered to live well, on good nourishing food, without 
regard to what it was, if no unpleasant effects were felt in the stomach. 
Her countenance had assumed a natural sprightly expression ; her strength 
was increasing; her dyspnoea decreasing, and everything appeared favour- 
able. She had rarely to take paregoric on account of the cough, but the 
blister was kept sore. In another month there was not a symptom of dis- 
ease remaining, except some cough and expectoration. And now, 25th 
December, she walks about the streets, straight and erect, not so strong as 
formerly, but can walk a mile or more without great fatigue. She weighs 
some pounds heavier than she ever did even in her younger days. Her sal- 
low countenance has all gone, and, although she is pale, she looks sprightly, 
talks, laughs with, and enjoys the intercourse of her friends as well as 
before she was sick. Her orthopncea has disappeared for two months, and 
she sleeps easy on either side, though rather more so on the left than right, 
and what I regard as among the most favourable signs is, her catamenia 
returned in December. 

She still coughs and expectorates, but not so much in a week as for- 
merly in a day — and the expectoration continues to diminish. The sounds 
in the chest are little more than a rather loud mucous rattle, with little or 
no puffing, or bronchophony. In the axilla is a portion in which there is 
no vesicular murmur, and only the mucous rale, but not strongly marked. 

The blister has not been applied for six weeks or more, and no incon- 
venience has resulted from letting it heal up. She is taking a tablespoonful 
of the oil twice a day. I am fearful yet of an attack of influenza, which is 
prevailing, to some extent, in her case. It would, in all probability, re- 
kindle the disease. But certain it is she is nearly well. I doubt very much 
whether any other article could have produced the effects that have resulted 
from this. Certainly it is not known, if it exists. All known means had 
been tried, and most faithfully too, before she commenced the use of this, 
and from no one, nor from all successively tried, did the slightest benefit 
accrue. 

I find much discrepancy of opinion concerning the kind of oil most me- 
dicinal. The kind used in the above case was the fine, clear, white oil. 
It cannot be procured for less than one dollar a pint. The coloured, coarse 
oil, at about half this price, or less, I have not recommended, because but 
few stomachs could bear it without nauseating, when continued for the 
length of time necessary. The effect of the other, instead of nauseating, is 
to improve the appetite, and the digestive, and assimilating functions, hence 
it ought to be preferred in all cases. It is to be apprehended that the high 
price of it will lead the dishonest to making an inferior imitation, that can 
be sold at a cheaper rate. In cases of this kind, as in many others, the 
cheap article is dearest in the end. I am trying it in three other hopeless 
cases of consumption, in which all other means have failed. They are all 
improved, but what will be the result time must develope. They have not 
taken enough yet to know what it will do. They all find an improvement 
in the appetite, and two of them express themselves as increasing in strength; 
their fevers and sweats are diminishing. 

Chester, Dec. 25, 1848. 



No. XXXIII.— Jan., 1849. 16 



238 



American Intelligence. 



[Jan. 



Case of extensive fracture of the Os Frontis, with escape of a portion 
of the Cerebral Substance. — Recovery. By J. Wistar Walke, M. D., 
of Chesterfield Coal Mines, Va. 

Marshall, a labourer in the coal mines of Chesterfield county, Vir- 
ginia, on the sixteenth of October, was precipitated, by the tumbling of 
coal, forward, and striking his forehead, an extensive fracture of the frontal 
bone was produced. Being, at the time of the accident, out of my neigh- 
bourhood, my assistance was not procured until seven hours after the injury 
was received. I found the entire integuments covering the frontal, and a 
part of the temporal, and parietal bones, turned back, and a fracture extend- 
ing from the centre of the left squamous portion of the temporal bone hori- 
zontally across to the nasal protuberance of the frontal, there taking a line 
upwards and backwards, forming an acute angle with the last mentioned 
fracture. Just at this place a triangular piece of bone, embracing the frontal 
protuberance of the leftside, was driven in upon the brain, and encroached 
upon the longitudinal sinus of the dura mater, lacerating many of the 
smaller vessels of the brain and its membranes, and separating from the 
cerebral mass a portion of its substance. 

Having no trepanning instruments at hand, I attempted, and succeeded, 
with instruments entirely unfit for the purpose, in elevating and accurately 
adjusting the fractured and depressed pieces of skull, completing the opera- 
tion by securing the scalp with the interrupted suture. 

The patient's mind was composed. After giving the necessary direc- 
tions I left the patient, and did not see him again in twelve hours, at which 
time I was surprised and gratified to find him doing well ; his pulse was 
about 75; the uneasiness about the head did not amount to pain; his mind 
was perfectly clear. 

I directed a saline cathartic, and almost total abstinence from nourish- 
ment, dark room, &c. At my next visit I found the patient quiet and free 
from pain ; pulse natural. This condition continued for some four or 
five days, when, on paying him a visit, I found considerable arterial ex- 
citement; the uneasiness about the head (probably) a little increased. I 
abstracted from the arm about fourteen ounces of blood, and directed a dose of 
sulphate of magnesia. The dietetic regulations were now more strenuously 
enforced. Upon my next visit I was much delighted to find that the reme- 
dies used at my last, had acted happily ; the pulse was reduced to the 
normal standard ; the pain in the head relieved ; a satisfactory operation 
upon the bowels, and at this, for the first time, I entertained hope for his 
recovery. The above were the only depletory means used throughout the 
entire management of the case. At this time (seven or eight weeks after 
the accident), the patient is doing well; the external wound is nearly 
healed, requiring, only, the argent, nitras occasionally to keep down the 
fungous granulations. The patient is walking about apparently as well as 
ever. 

There has been nothing like hebetude of mind whilst awake, nor confused 
dreams and wanderings during sleep, which was generally uninterrupted 
as far as I could ascertain. 

Dec. 4, 1848. 



1849.] 



Domestic Summary. 



239 



DOMESTIC SUMMARY. 

Case of Compound Fracture of the Cranium loilh loss of Cerebral Substance. By 
Elias Horlbeck, M. D:, of Charleston. (Charleston Med. Journ.. Nov., 1848.) — 
This case is interesting from the slight symptoms of cerebral lesion, considering 
the actual injury sustained. The subject of it was a negro boy seventeen years of 
age, who was wounded, July 22, by a brick-bat falling on his head from a height 
of about seventy-five feet. He was stunned by the blow, and when seen by Dr. 
H., fifteen minutes after the accident, he was lying as if quietly asleep, breathing 
naturally and without stertor. The surface of his body cool and harsh to the feel- 
ing. Pulse small, sluggish and easily compressed, beating sixty pulsations to the 
minute. The pupils of the eye unaltered. He is easily roused, especially when 
the wound in the scalp is handled, answers when spoken to, says his neck pains 
him. 

On examining the wound, which was situated on the upper part of the frontal 
bone, not far from the parietal, and extended three or four inches towards the outer 
angle of the eye, and turning down its flap, Dr. H. perceived its cavity occupied 
by a considerable quantity of cerebral substance. Wh«n this was removed a well 
defined hole in the skull, as large as a dollar, corresponding with the external in- 
jury, appeared, presenting a smooth surface leading into the cavity of the cranium. 
Dr. Wragg, who had been also summoned to the accident, opportunely came in 
at this moment and gave his assistance. The bone had been starred, as it were, 
by the blow, and driven in on the brain. No loose pieces could be felt, they being 
all tightly wedged in by the depressing influence. With much difficulty and by 
means of an elevator some pieces of bone were removed. The dura mater torn 
through, so as readily to admit the finger, and through this rent could be felt other 
fragments which had been driven in and buried in the substance of the brain itself. 
Dr. H. with great caution succeeded in extracting eight or ten pieces belonging, 
apparently, to the internal brittle table of the bone, and with them some cerebral 
substance also came away. More of it could be felt in a pulpy state, evidently 
much injured by these foreign bodies. What is singular was that not one of the 
fragments had any connection with the dura mater, being all completely isolated. 
During all these manipulations the patient manifested little or no suffering, wincing 
only when the divided scalp was handled. 

" Being satisfied that nothing extraneous was left behind, the wound was more 
carefully cleansed, and having ceased to bleed, the edges were approximated by 
four interrupted sutures, assisted by two adhesive straps. These were so arranged 
that even if adhesion by first intention should occur, which was not probable from 
the contused nature of the wound, a sufficient outlet would be left for the suppura- 
tion and injured parts of the brain to be discharged. 

11 All the symptoms were such as are met with in simple concussion of the brain. 
The languid circulation, absence of paralysis and stertor, facility of being roused 
when spoken to, indicated that no compression existed. The loss of brain, which 
up to this time was over a teaspoonful, appeared to have no effect in the causation 
of his symptoms. 

"Visited him at 7 P.M., and found his situation nearly as above described; he 
had not suffered, though he had been removed at least half a mile. Directed an 
infusion of senna with Epsom salts in the course of the night; cold applications 
to be made to the head ; perfect quiet and absolute diet. 

" 23d. Pulse 64, sluggish, without force; skin still cool; eyes of a more intelli- 
gent expression; he remains awake longer after he has been roused, puts out his 
tongue when told to do so, and answers, though in an indistinct manner, when 
spoken to. The purgative has operated several times, and, when the occasion 
called, he got up to the stool with very little assistance; adjusted the bandages and 
continued the cold water dressings. 

u 24th. Pulse 65, small and feeble; the surface cool, has lost some of its rough 
feeling; lies quietly in bed; complains of his neck and ears when his attention's 
called to it; pulpy cerebral matter mingled with blood discharging from the ex- 
tremities of the wound; bowels continue to be moved; allowed him a little warm 
tea or gruel. 



240 



American Intelligence. 



[Jan. 



" 25th. On removing the dressings a good deal of cerebral matter with bloody pus 
was found in them, and more was gently pressed from the wound, which occa- 
sioned him no pain, or not more than would have resulted from a simple uncom- 
plicated wound of the scalp. He seems to be recovering from the state of con- 
cussion. Pulse 68, with no impulse or hardness; skin warmer; complains more 
of his head and had passed rather a restless night, but at present feels hungry and 
asks for something to eat; a thin slice of bread and warm tea allowed. 

"26th. Better night, his intellect clear; eyes natural; expression of countenance 
as in health ; discharges less in quantity, but of the same character. Those parts 
of the wound which have not healed, give out a little healthy pus; some granula- 
tions springing up ; an elastic fulness, having a pulsatory movement, sensibly per- 
ceptible. 

" 27th. Pulse 70 ; skin comfortable ; all his symptoms improved ; had eaten a thin 
slice of bread and cup of tea, w T ith appetite ; bowels kept loose, when necessary, 
by salts and senna. 

" 29th. Sitting up in bed. 

" Aug. 1st. He has been kept quiet, and on short diet; complains that they do not 
give him enough to eat ; the edges of the wound have healed at the points where 
the sutures have been used, having united in about two-thirds of their extent; 
granulations rather exuberant; suppuration healthy, consisting wholly of laudable 
pus, there being now no cerebral matter discharged. The flap of the skin is a 
little depressed below the level, and at this point the pulsations of the brain can 
be seen and felt. The probe, when introduced, can be passed under the wound, 
from one suture to another, and the exposed bone felt at one or two points, which 
made us apprehend some exfoliation. Cold water dressings continued, with mo- 
derate pressure, by means of a compress and bandage. 

" 7th. Touched the rather flabby granulations with caustic; wound contracting 
and healing ; appetite good." 

From this time he steadily improved; the wound had entirely healed on the 
27th August, and at the date of the report (Oct. 15), was engaged in driving a 
dray, and feels as w T ell as before the injury. 

A similar case is recorded by Dr. Fox (see p. 43), and another by Dr. Walke 
(p. 238), in the present number of this Journal. 

(Edematous Laryngitis, successfully treated by Scarifications of the Glottis and Epi- 
glottis. By Gurdon Buck, Jr., M. D., Surgeon to the New York Hospital. (Trans, 
of the American Med. Association, vol. i.) 

The following is the mode adopted by Dr. Buck for scarifying the glottis and 
epiglottis in the cases he relates. 

"The patient being seated on a chair, with his head thrown back, and supported 
by an assistant, he is directed to keep his mouth as wide open as possible; and 
if there be any difficulty in this respect, a piece of wood an inch and a quarter 
in width, and half an inch in thickness, is to be placed edgewise between the 
molar teeth of the left side. The fore-finger of the left hand is then to be intro- 
duced at the right angle of the mouth, and passed down over the tongue till it en- 
counters the epiglottis. 

" But little difficulty is generally experienced in carrying the end of the finger 
above and behind the epiglottis so as to overlap it and press it forwards towards 
the base of the tongue. In some individuals the finger may be made to overlap 
the epiglottis to the extent of three-fourths of an inch. 

"Thus placed, the finger serves as a sure guide to the instrument to be used, 
which is represented accurately in the accompanying plate. (See Fig 2.) The 
knife is then to be conducted with its concavity directed downwards, along the 
finger till its point reaches the finger nail. By elevating the handle so as to 
depress the blade an inch to an inch and a half farther, the cutting extremity 13 
placed in the glottis between its edges (see Fig. 1) ; at this stage of the operation 
the knife is to be slightly rotated to one side and the other, giving it a cutting mo- 
tion in the act of withdrawing it. This may be repeated without removing the 
finger, two or three times on either side. The margin of the epiglottis, and the 
swelling between it and the base of the tongue may be scarified still more easily 



1849.] 



Domestic Summary. 



241 



with the same instrument, or scissors curved flatwise (see Fig 3) maybe em- 
ployed for these parts, guided in the same manner as the knife. 

" Though a disagreeable sense of suffocation and choking is caused by the 
operation, the patient soon recovers from it, and submits to a repetition after a short 
interval. In every instance the operation has been performed twice, and in some 
three times. < 

" Before proceeding to the operation, it has always been explained to the patient, 
that the seat of his difficulty was a swelling at the top of the windpipe, prevent- 
ing the air from entering, and the object of the operation was to cut it and let out 
fluid and thus give him relief. This explanation corresponds so exactly with his 
own sensations, which refer to the top of the thyroid cartilage as the seat of obstruc- 
tion, that he readily submits to the proposed operation, and renders all the co-opera- 
tion in his power for its performance. 

"A slight hemorrhage follows the scarifications, and should be encouraged by 
gargling with warm water. In one instance the quantity of blood mixed with 
sputa amounted to half a wineglassful." 

Dr. Buck states, that during the short period of eleven months, no less than 
eight cases of cedematous laryngitis occurred in the New York Hospital, and of 
these Dr. B has given the details of five cases ; the other three terminated fatally, 
and their post-mortem appearances are detailed. Scarifications had not been re- 
sorted to in these last. Of the successful cases we select the three following. 

The first case in which Dr. Buck employed the operation he describes, was the 
following: 

" Case 1. — Arthur W. Taylor, seaman, born in New York, aged thirfy-one years, 
was acting as nurse in Ward No. 4, South Building, New York Hospital. For tw T o 
days previous to the 13th of April, 1847. when his case was first noticed, he had 
suffered from painful deglutition, with elongation of the uvula, that kept up acon- 
stant tickling sensation- — the fauces also presented an inflamed appearance. The 
epiglottis w 7 as seen as well as felt to be swollen. Breathing was difficult, and at- 
tended with paroxysms of suffocation. 

" A stimulating gargle had been used, and on the morning of the above date, 
the uvula had been excised with some relief. Six leeches had been applied over 
the larynx, and the bites were still bleeding at the time of the regular visit at 
noon. After exploring the parts with the finger, and ascertaining the existence of 
swelling of the epiglottis, and also allowing my two assistants to do the same, I 
scarified the aryteno-epiglottic folds and the epiglottis, partly with scissors curved 
flatwise, and partly with a sharp pointed curved bistoury, guarded to within one- 
third of an inch of its point by a narrow strip of adhesive plaster wound around 
it, and conducted to the parts upon the forefinger of the left hand, previously in- 
troduced at the right angle of the mouth. Two or three repetitions were requi- 
site, at short intervals, to complete the operation. The patient hawked up three 
or four teaspoonsful of blood, mixed with mucus, and expressed himself as feel- 
ing relieved. Twenty ounces of blood were drawn from the arm soon after, and 
grain doses of tartar emetic administered. 

"On the following day (the 14th), an improvement in the respiration had evi- 
dently taken place. 

"On the 15th, respiration was still further improved, the pulse was 84, and soft; 
patient complained of soreness of the scarified parts. Antimony was stopped. 
"On the 17th he was much improved in all respects, pulse 68. 
" On the 23d he was discharged cured." 

" Case II.— On the 13th of January, 1848, I saw, at Dr. Swett's request, Daniel 
McGraw, aged thirty years, a farmer, born in Ireland, (in Ward No. 8, North 
Building, New York Hospital.) who was attacked the evening previous with sore 
throat, difficulty of swallowing and dyspnoea. 

" Inhalation of Vapour of warm water, poultices to the neck, and a blister over 
the sternum had afforded him no relief. ' Patient's countenance was pale and had 
an anxious expression, his lips were livid. Inspiration was difficult and laboured, 
expiration easy. 

"The voice was altered and hoarse. The velum, uvula and tonsils were mo- 
derately swollen, red, and coated with a grayish-yellow viscid secretion. Wilh 
the forefinger the epiglottis was distinctly felt to be swollen, and its margin thick- 



242 



American Intelligence. 



[Jan. 



ened and folded together. The pouches between it and the base of the tongue 
were filled up by a soft pulpy swelling. Dr. Swett also explored the parts and 
found them as described. At 10| o'clock A. M. I scarified the edges of the glottis 
as well as the epiglottis, aud the swelling anterior to it, with a sharp pointed curved 
bistoury and curved scissors, as in Case I. 

" Slight hemorrhage followed, and was encouraged by a warm water gargle. 
The exploration of the parts, as well as the operation itself, did not' cause much 
disturbance, and patient expressed decided relief. A solution of nitrate of silver 
twenty grains to the ounce, was applied to the fauces one hour after the operation 
and once the following morning. 

" At 2| o'clock P. M., the same day, patient breathed more calmly and felt still 
further relief. He passed the following night very comfortably, and the next 
morning expressed himself quite well. The swollen parts were ascertained by 
the touch to have very much diminished. His further progress continued favour- 
able without any repetition of the scarifications. 

u This patient had been in the ward since the 29th of the preceding month with 
ship fever of a mild type, and was considered as making favourable progress at 
the time of the above attack." 

" Case IV was a patient of Dr. Swett in Medical Ward No. 9, North House, 
New York Hospital, named James Rourke, aged 27 years, born in Ireland. On 
Tuesday, February 28th, 1848, at 2^ o'clock P. M. was suffering with well marked 
symptoms of cedematous laryngitis, that had supervened in the progress of tylhus 
fever at about the end of the third week. An abundant petechial eruption, great 
prostration, subsultus tendinum, and extensive bronchitis had characterized the 
fever. A supporting and stimulating plan of treatment had been pursued, and a 
large blister had been applied over the chest within a day or two for the relief oi 
the bronchitis. Patient was also taking Stokes' expectorant. When seen, his 
breathing, especially during inspiration, was difficult and sonorous, and his voice 
hoarse. 

"There was some soreness of the throat with a copious expectoration of viscid 
mucus. 

" The velum and fauces were of a deep red colour, clean and free from swell- 
ing or exudation upon their surface. With the finger, the edge of the epiglottis 
was felt thickened, swollen and pulpy, by Dr. Swett, as well as myself. The 
glosso-epiglottic freenum and pouches on either side were not swollen. 

" I scarified the edges of the glottis and the epiglottis, two or three times at a 
few moments' interval, which was followed by slight hemorrhage, and from which 
patient admitted that he felt some relief, though from the confused state of his in- 
tellect incident to the fever, his own testimony was considered doubtful. 

" Some difficulty was experienced in the operation, from the involuntary clos- 
ing of the jaws as if by a movement of subsultus, by which the left forefinger was 
compressed between the teeth. The instrument used was the curved knife. On 
the following day, patient was found to have passed the night comfortably and 
was no worse, the hoarseness and dyspnGea were about the same; no paroxysms 
of suffocation had as yet supervened. Stokes' expectorant and stimulants were 
continued. 

" Second day, 4 o'clock P. M. — Patient is decidedly worse, dyspncea very much 
increased, paroxysms of suffocation and choking have now supervened, and are 
excited by attempts to swallow and on falling asleep, during which the face and 
lips become livid. The pulse is eighty, full and quick, the skin warm and dry, 
the tongue brown and dry, and the throat clogged with viscid mucus; the epiglottis 
is felt to be much more swollen. I repealed the scarification very freely, taking 
the precaution to insert a piece of wood between the molar teeth on the left side 
to protect my finger. More hemorrhage followed the scarifications than in any 
previous operation. At least one ounce of florid blood was hawked up mixed with 
mucus, and patient expressed himself very much relieved. After this there was 
no recurrence of paroxysms. 

" Third day. — The case is going on favourably, respiration is decidedly easier, 
the pulse is good and 80 per minute. 

u Fourth day. — The improvement continues, the tongue has become white and 
moist, and the temperature of the surface more moderate. The epiglottis has 



1849.] 



Domestic Summary. 



243 



nearly resumed its natural condition. Stokes' expectorant has been continued and 
the blistered surface kept sore. In a few days after, the voice recovered its natural 
tone, and the patient began to leave his bed. He was discharged March 30th, 
cured." 

In the fifth case, in view of the urgency of the dyspnoea and imminent danger 
attending it, Dr. Swett as well as Dr. Buck thought it prudent not to rely exclu- 
sively upon the scarifications, but to give the patient the additional chance of tra- 
cheotomy, which was accordingly performed, and was followed by the happiest 
effects. 

The results obtained under the treatment by scarifications in the cases which 
have come under the observation of Dr. Buck have far exceeded his most san- 
guine expectations. " In every instance/' he says, " a favourable result followed 
the use of scarifications. In Cases IT. and IV. no other efficient auxiliary treat- 
ment was employed; scarifications alone were relied upon ; and, though in Cases 
I. and III. venesection, leeches, emetics, mercury, &c , were also employed, it 
was very obvious that no benefit was derived from them, and that no relief was 
experienced till the operation was resorted to. 

" It is true that in Case V. tracheotomy, which has proved efficacious in this 
disease when early performed, was resorted to on account of the imminent dan- 
ger of suffocation that threatened the patient : yet, if the particulars of this case are 
carefully considered, evidence may be derived from it tending to strengthen our 
confidence in the efficacy of scarifications, if not to show, that even in this particu- 
lar instance, they might have been exclusively relied upon. It will be borne in 
mind, that twenty-four hours after the operation of tracheotomy, on closing the 
opening of the trachea, by compressing the edges of the wound together, the pa- 
tient could already breathe through the larynx with a good degree of facility, and 
the epiglottis itself was felt to have diminished in size. At the expiration of forty- 
eight hours, on closing the outer orifice of the tube, which accurately filled up the 
opening in the trachea, the patient was able to breathe without effort, showing 
conclusively that the obstruction of the larynx had disappeared. The epiglottis 
had also resumed its natural size. 

"That the removal of the obstruction of the larynx in this case was very rapid 
will appear by comparing it with what has been observed in other analogous cases 
after tracheotomy. 

" Mr. Porter (06.9. on the Surg. Path, of the Larynx and Trachea, London, 1837, 
p. 103) states, that in a very urgent case of oedema of the glottis, where tracheo- 
tomy was performed. ' the subsequent progress was, in every respect, as favourable 
as the operator could wish. The patient had calomel and opium to the extent of 
affecting his mouth. In a few days he was able to respire partially through the 
glottis,' &c. Mr. Porter also says (in Med.-Chir. Trans., vol. xi. p. 422), of a pa- 
tient, -on the third day after tracheotomy had been performed, under the most 
urgent circumstances in this disease, that he had one or two attacks of convulsive 
breathing from the wound being obstructed. He was sometimes obliged to resort 
to the natural opening, and to use strong muscular exertions in inspiration,' &c. 
&c. This patient was also taking mercury freely. Mr. Lawrence (in the Med.- 
Chir. Trans., vol. vi. p. 253) says of his patient, ' on the ninth day after tracheo- 
tomy, he was sufficiently recovered to get up. By holding the edges of the wound 
together he could breathe through the larynx and speak, but there was still a 
feeling of difficulty which made it necessary to open the wound again in a short 
time.' 

"Mr. Wood (in Med.-Chir. Trans., vol. xvii. p. 159) says of a patient, ' on the 
fourth day after tracheotomy, she breathes easily except when the artificial opening 
is obstructed by mucus. 7 Ptyalism was also produced in this case. 

"All of these cases recovered. The obstruction of the larynx, however, was 
slow and gradual- in its disappearance, and, in three of them, the progress of 
absorption was aided by the mercurial action. 

" It may. therefore, I think, be fairly inferred that the rapid removal of the ob- 
struction in the case under consideration, is to be attributed to the free scarifica- 
tions that had preceded the operation of tracheotomy, and in all probability they 
alone might have been relied on to accomplish the desired object. The mechani- 
cal obstruction to the entrance of air into the larynx, produced by the cedematous 



244 



American Intelligence. 



[Jan. 



swelling of one or both edges of the glottis, with the spasm induced by it, consti- 
tutes the essential and dangerous feature of this disease, and one which will admit 
of no delay in its removal. 

" In the almost constant failure of other means to accomplish this object, the 
operation of tracheotomy has been very properly recommended by the best medi- 
cal authorities to be early resorted to. 

" By this means an artificial entrance is provided for air into the lungs, by 
which life is supported, and time gained for the gradual removal of the obstruc- 
tion. 

" The operation now under consideration aims at the removal of the obstruction 
itself in the most direct manner, and the results already obtained may well en- 
courage the hope that this formidable disease will not hereafter bear such fatal 
sway as the annals of medical science show it to have done heretofore. 

"In respect to the difficulties of the operation, it may be remarked that those 
which exist on the side of the patient are — 1st. Irritation and disturbance of the 
affected parts themselves produced by the presence of the finger and instrument. 
These, as has already been incidentally remarked in the report of the cases, have 
not been so great as to prevent the accomplishment of the operation or deter from 
its repetition. The patient soon recovers from them, and in every instance two 
or three repetitions, at intervals of three or four minutes, have been submitted to. 
In one instance only (Case III.), did the patient require urging. 2d. As this 
disease sometimes supervenes in the progress of phlegmonous inflammation affect- 
ing the parotid or submaxillary regions, and attended with rigidity of the lower 
jaw, the difficulty of separating the jaw might be insurmountable. In this case 
tracheotomy would be the only resource. The most suitable means of overcom- 
ing the obstacle in such a case, would be the cautious use of wooden wedges to 
pry apart the jaws. 

"The difficulties on the part of the operator, where the requisite knowledge of 
the anatomical relations of the parts and the necessary skill are possessed, are 
by no means formidable. The accompanying plate, (Fig. 1.) together with the 
description already given of the operation, it is believed will render the subject 
sufficiently plain. 

" The dangers of the operation are either of producing suffocation by exciting 
spasm, or of inflicting injury with the knife on neighbouring parts. In regard to 
the first, more extensive experience alone can decide the question. In Cases III. 
and IV. it was submitted to a severe test ; at all events the danger from this source 
can scarcely be equal to that of the disease itself. 

"In regard to the danger of wounding neighbouring parts, the action of the 
knife is limited on either side by the sides of the thyroid cartilage, which shut in 
the glottis, and render access to the great vessels impracticable. In the swollen 
state of the lining membrane, the scarifications, unless carried to an undue extent, 
would not be likely to involve anything beyond the membrane itself. 

"It will be for future experience to determine in what particular conditions of 
this disease the operation may be inapplicable. The advantages of its early ap- 
plication are shown in Cases T. and II.; and in Case III. the patient's obstinate 
refusal to submit to tracheotomy compelled our sole reliance on scarifications^ 
and that in circumstances of the most imminent danger from impending suffo- 
cation. 

"Although cedema of the glottis is a disease confined to adult age, yet an 
analogous condi'ion of the larynx is accidentally produced in children by their 
attempting to drink scalding water from the spout of a tea kettle. Numerous 
cases of this accident have been reported, in which death took place from suffo- 
cation, with symptoms of croup, and in which the edges of the glottis and epi- 
glottis were found swollen and blistered. A few of these cases have been saved 
by tracheotomy. Scarifications would seem to be equally applicable for their 
relief, and Dr. Marshall Hall, in 1821, (Med.-Chir. Trans., vol. xii ,) after relating 
four cases of this accident, observes, in remarking on the treatment: — c If the 
suffocation were imminent, I should not hesitate to propose laryngotomy or tra- 
cheotomy, and the former would appear to reach below the seat of the affection. 
But I now regret that I did not propose the scarification of the epiglottis and 
glottis, so as to evacuate the blisters.' The suggestion of this distinguished 



1849.] 



Domestic Summary. 



245 



physician does not appear to have been carried into effect, or even noticed by 
those who have treated of this subject since it was made. Dr. Jameson, in his 
Observations on (Edema of the Glottis from attempts to swallow boiling water, 
{Bub. Quart. Juurn. of Med. Sci., No. IX., Feb. 1848.) makes no allusion to it. 

"Lisfianc has proposed making punctures (mouchetures) of the swellings in 
cedemaof the glottis, of which Cruveilhier says, (Diet, ele Med. et de Chir. Pratique, 
tome ii. p. 41, 1834,) 'I doubt whether this "little operation has ever been per- 
formed.' Mr. Ryland (A Treatise on the Diseases and Injuries of the Larynx and Tra- 
chea, Philadelphia, 1838, p. 51) says of this method, and oi that of M. Thuillier, 
which consists in making pressure from time to time by means of the finger 
upon the distended lips of the glottis, to promote the absorption of the effused 
serum, 'b.oih plans are fantastic, very difficult, if not impossible, of accomplish- 
ment, and more likely to increase than diminish the existing mischief.' " 

Mr. Busk, at a meeting of the Royal Med. and Chir. Soc, March 9, 1847, 
(London Lancet, March, 1847.) related 'two cases treated successfully by making 
a great number of minute punctures on the back of the tongue, the uvula, and 
pharynx, with a sharp pointed bistoury, and repeating them every half hour for 
two or three hours.' 

"These are the only methods of treatment analogous to the one under con^ 
sideration that have been hitherto proposed by others, so far as my researches 
have ascertained.^ 

"The question of diagnosis in this disease is one of vital importance, irre- 
spective of the present operation, but in connection with it its importance becomes 
very greatly enhanced. Without stopping to notice the distinctive symptoms 
which have been generally regarded as characteristic of this disease, or those of 
other diseases that are most likely to be mistaken for it, I beg leave to insist upon 
one sign which is strictly pathognomonic, and does not appear to have been suffi- 
ciently appreciated. 

" I refer to the swelling of the epiglottis as ascertained by the touch. The dis- 
covery of it, according to Bayle, (Diet, cles Scien Med., tome xviii. p. 507,) is due 
to M. Thuillier, who proposed it in a thesis sustained before the Faculty of Medi- 
cine in Paris, in 1815. The value of this sign will be admitted if we consider 
how frequent the swelling of the epiglottis co-exists with that of the glottis. 
Bayle, (loc. cit.,) who dissected more than seventeen cases of this disease, says, 
'the epiglottis is rarely intact, often it is very much swollen at its edges.' Ry- 
land says, (loc. cit., p. 48,) 'The oedema is seldom confined to these localities, 
but extends to ihe base and lateral edges of the epiglottis, &c.' 

"Among seventeen cases collected from different sources, and in which the 
condition of the epiglottis was ascertained, either by dissection after death, or by 
the touch or inspection during life, swelling was found in fifteen. Of the eight 
cases reported in this paper, the epiglottis was found swollen in seven, and in the 
remaining one there was no evidence that it was not swollen. 

"This swelling takes place either at the margin on one or both sides of the 
median line, or on the lingual surface of the epiglottis at its base, filling up one 
or both depressions between it and the tongue, and obliterating the central glosso- 
epiglottic frsenum. 

" It conveys to the touch the sensation of a soft pulpy body, easily recognized 
and distinguished from the stiff rigid swelling of these parts in membranous 
laryngitis. 

" The facility of ascertaining the condition of the epiglottis with the end of the 
forefinger, not only by placing it in contact with its anterior surface, but by pass- 
ing over its upper edge, and applying it upon its posterior surface, has been 
already noticed. 

" To test this question still further, the experiment has been repeated in at least 
twelve individuals, and in all with success, though not with equal facility. In 
some these parts were easier of access than in others, but in none did the expe- 
riment fail. 

" In the exceptional cases where the epiglottis is not found swollen, the edges 
of the glottis may be brought more within reach by pressing up the os hyoides 



• See Note at the end of this paper. 



246 



American Intelligence. 



[Jan. 



with one hand applied externally over it, and acting from below upward, while 
the forefinger of the other hand is introduced as directed into the mouth. 

"Should this not accomplish the object, the fore and middle finger maybe 
thrust far back into the pharynx, as is required for the removal of a foreign body 
lodged in the throat. 

" In all the five cases treated by scarifications, it will be remembered that the 
test of touch was applied, not only by myself, but by one or move of my col- 
leagues or assistants, and thus the diagnosis of the disease was established beyond 
doubt. 

"To those who have encountered this formidable disease, this subject will 
possess peculiar interest; and the remedy proposed, perhaps, may be hailed by 
them as a valuable improvement in the healing art. 

" Time and experience alone can determine this question. To this test I desire 
to subject it after having, as I believe, faithfully recorded and made known the 
results of my own experience. 

" In conclusion, I desire to express my grateful acknowledgments to Drs. R. 
K. Hoffman and John A. Swett, my highly esteemed colleagues at the New York 
Hospital, for the opportunities they kindly afforded me of applying the new treat- 
ment upon their patients, and also to my pupil, Mr. Moreau Morris, for the accu- 
rate and beautiful drawings accompanying this paper, and so indispensable for 
its illustration. 

"Note.— Since this paper was laid before the American Medical Association 
at its recent meeting, 1 have had access to Vaileix's work, entitled Guide da Me- 
decin Practicien, tome i. p. 481, Paris, 1842, giving a detailed account of M. Lis- 
franc's operation, respecting which it seemed doubtful, from the very slight notice 
taken of it by earlier authorities, especially Cruveilhier, whether it had ever been 
performed. M. Valleix says, 'M. Lisfranc (Mem. sur V Ang. Laryng. (E<hm., 
Joarn. Gen. de Med., tome Ixxxiii., 1823) first conceived the idea of evacuating, 
by means of incisions more or less numerous, the serous or sero-purulent fluid 
engorging the submucous tissue of the larynx. This surgeon cites five cases in 
which this operation was followed by an immediate change, and subsequently by 
a complete cure. In a sixth case, several similar operations at variable intervals 
acted only as palliatives. Extensive lesions of the larynx existed, which at length 
caused the death of the patient. 

" 'The following is M. Lisfranc's method of scarifying the larynx. Take a 
long narrow- bladed slightly curved bistoury in a stiff handle, protected with a 
strip of linen to within half an inch of the point. Let the patient open his mouih 
wide, and have the jaws kept apart by means of a cork placed far back between 
the molar teeth, one end of the cork being held by an assistant. The patient 
being placed in front of the operator, with his head supported against the breast 
of an assistant, pass the index and middle finger of the left hand into the mouth 
till they reach the swollen edges of the larynx, glide the bistoury flatwise upon 
the finger, holding it as you would a pen. On reaching the larynx direct the 
edge forward and upward, then ; after having elevated the handle, depress it 
gradually, at the same time pressing gently upon the point. At first, a few punc- 
tures only should be made, as by the aid of pressure two or three smail incisions 
are sufficient. They may easily be multiplied in the same way if judged 
necessary. 

" c These scarifications, says M. Lisfranc, produce a flow of the infiltrated matter 
and sometimes a slight oozing of blood, which effects a salutary disgorgement. 
The cough excited by a few drops of serum falling into the larynx, contributes 
much to diminish the swelling. The immediate beneficial results of these scari- 
fications might be partially defeated, by their occasioning more or less inflamma- 
tion of the larynx and surrounding parts. In such a case recourse must be had to 
general or local bleeding ; which would soon disperse this traumatic inflammation. ' 

" It appears also, from M. Valleix's statement, that Professor Marjolin has lace- 
rated the cedematous edges of the larynx with a piece of althea root, and M. Le- 
groux with the nail of the index finger sharpened for the purpose, and both with 
success." 



1849.] 



Domestic Summary. 



247 



Fig. 1. 




"Fig. 1 represents a transverse perpendicular section through the base of the cranium 
and between the pharynx and cervical vertebrae. The pharynx is laid open and exposes 
posteriorly the nares, velum, uvula, base of the tongue and glottis, with the left forefinger 
applied upon the epiglottis and pressing it forwards against the base of the tongue; the 
curved knife is placed with its cutting extremity in the entrance of the glottis between 
its edges, which are represented as CBdematous." 



248 American Intelligence. 

Fig. 2. Fig. 3. 



[Jan. 




1349.] 



Domestic Summary. 



249 



A Xeic Feature in the Anatomical Structure of the Genito-Urinory Organs not hitherto 
described. Bv Gurdon Buck. Jr.. ML D., Surgeon to the New York Hospital. &c. 
{Transactions of the American Medical Association, Vol. I.) 

The anatomical structure in question consists of a distinct membranous sheath 
investing the penis in the manner to be described, and forming a continuation of 
the suspensory ligament above, and of the perineal fascia below, and will be be^t 
understood by a description of the mode of dissecting it. 

The penis and scrotum are to be circumscribed by an incision at the distance of 
three finders breadth all around; and crossing the perineum at the anterior margin 
of the sphincter. 

The dissection of the skin and subjacent cellular and adipose tissues is to be 
made towards the penis, on the level of the fascia lata laterally, and of the perineal 
fascia posteriorly, and carefully continued to the body of the penis, as far as the 
corona glandis. By this means, the penis, as well as the suspensory ligament, is 
denuded of its loose movable investments. 

An incision is then to be made along the dorsum of the penis, exactly in the 
median line, splitting through the suspensory ligament, and extending forward to 
the corona, between the dorsal vessels and nerves that run parallel on either side. 
The adhesions of the sheath along the dorsum are firm, and require careful dis- 
section; the blood-vessels and nerves being raised with it ; serve as a guide to show 
the line of adhesion. 

The dissection being prosecuted laterally as well as inferiorly and at the ex- 
tremity, the entire corpus cavernosum is enucleated, the muscles of the perineum 
being raised with the sheath. It is now clearly seen that the suspensory ligament 
from above, and the perineal fascia from below and laterally, form one continuous 
membrane with the sheath, inclosing the corpus cavernosum in its cavity, and 
embracing the corpus spongiosum urethra? between two layers, one of which 
passes above, and the other below it. The excavated base of the glans adheres 
inseparably to the outer surface of the sheath, while, by means of its inner surface, 
it caps the summit of the corpus cavernosum. 

Its adhesions are most firm at the extremity of the corpus cavernosum, along its 
dorsal surface, and at the insertions of the erector and accelerator muscles. 

It is thickest around the corona ; along the dorsal surface, and where it forms the 
suspensory ligament. 

Zones of vessels run at regular intervals in the direction of the circumference 
of the penis, from the dorsal trunks to the corpus spongiosum, between the layers 
of the sheath. 

The cavity formed by the sheath, and occupied by the corpus cavernosum, is 
limited posteriorly by the triangular ligament. 

That portion which covers the perineal muscles, and has been described by 
authors under the names of the superficial fascia of the perineum, inferior fascia 
and ano penic fascia, arises laterally from the ascending rami of the ischium, and 
descending of the pubes, as far forward as the inferior edge of the symphysis, 
where the two layers meet and form the suspensory ligament. Posteriorly, it is 
continued over the transverse muscles, and folding around their edges is prolonged 
upwards into the ischio-rectal fossa. 

It also sends off, from its upper surface, membranous septa between the accel- 
erator muscles in the middle, and the erectors on either side, to join the triangular 
ligament, and thus forms three distinct and independent sheaths that are confounded 
anteriorly with the common sheath investing the corpus cavernosum. 

M. Velpeau-s description of this fascia (Traite d'Anatomie Chir., 3me edit., Paris, 
1837, tome ii. p. 214) is the most minute and accurate. He says of it, in addition 
to the above — " that it is insensibly lost in front upon the body of the penis. " ; Mr. 
T. Morton (in his Treatise on the Surgical Anatomy of the Perineum, London, 1838, 
p. 12) says of it, that — -anteriorly it passes forwards into the scrotum, where it 
appears to become continuous with the dartos." 

Colles, who has given the most accurate description of the sheath of the penis 
(in his Treatise on Surgical Anatomy, 2d Amer. edit., Phila., 1831, p. 146) says — 
on raising the skin we find a ligamentous membrane which invests the penis, 
and which is derived from he suspensory ligament:' 7 further on he adds — ; -This 



250 



American Intelligence. 



[Jan. 



ligament, adhering by its upper edge to the symphysis pubis descends and fixes 
itself by its lower edge to the dorsum penis, but it does not cease here, for it can 
be traced, expanding itself over the crura of the penis and urethra, until it ter- 
minates at the base of the glans, thus constituting one of the envelops of the 
penis." 

Other modern anatomists, such as Malgaigne, Cruveilhier, A. Berard, &c, have * 
contributed nothing to render our knowledge of these parts more complete than, 
the authorities just quoted. 

The present statement, besides embracing what has been described by Velpeau 
and Colles, shows the peculiar relations of this sheath to the corpus spongiosum 
urethra? and the glans penis, which, so far as my researches have extended, have 
not hitherto been described by anatomists. 

Important pathological relations have been shown by Velpeau to depend on the 
peculiar structure of these parts as described by himself, especially in the formation 
of abscesses, and extravasation of urine anterior to the triangular ligament. The 
more complete development of their anatomical relations set forth in this paper, 
serves to confirm these pathological views, and throw additional light upon 
them. 

The following case of extravasation affords a good illustration. 

Case I. — Charles Peak, a seaman, aged thirty-four years, born in England, was 
admitted into the New York Hospital, February 29th, 1848, with a circumscribed, 
hard, prominent swelling, of the size of a Madeira nut, in the anterior part of the 
scrotum, covering and closely embracing the urethra, and also extending on either 
side around ihe root of the penis, in the form of an indurated flattened band. 

It was very tender to the touch, and contained matter, as was evident from deep 
fluctuation. The superjacent cellular tissue and scrotum retained their natural 
suppleness and mobility, and did not participate at all in the deep inflammation. 
A stricture of the urethra, admitting only the smallest sized bougie, was found 
within the swelling, and had existed for more than a year. 

About three weeks before admission, the swelling in the scrotum first appeared 
of the size of the end of the finger, after the introduction of a wire sound by the 
patient himself. 

A deep free incision into the tumour evacuated a quantity of fetid urine mixed 
with pus; and for some time subsequent, urine continued to escape through the 
wound, in small quantities. 

In this instance, the rupture of the urethra had taken place within the sheath of 
the corpus cavernosum at the stricture, and the inflammatory swelling consequent 
on the extravasation of urine was thus confined to the narrow limits described; 
the communication between the urethra and loose superjacent cellular tissue being 
shut off. 

Left to itself, the swelling sometimes gradually approaches the surface, by ap- 
propriating to itself, by the adhesive inflammation, the successive layers of cellular 
tissue covering it, and at length evacuating its contents externally, through an ul- 
cerated opening. This, however, is not uniformly the case. It often happens that 
the ulcerative process within the abscess goes on in advance of the adhesive and 
conservative process on the outside, and opens a communication into the loose 
cellular tissue covering it, the consequence of which is rapid extravasation in 
every direction, filling up the scrotum, spreading up over the pubes, and sometimes 
extending along the crest of the ilium as high as the false ribs. It is probably rare 
that this extensive secondary form of extravasation is not preceded by the circum- 
scribed or primary form, hence the importance of the established rule of practice; 
to make a free opening into these hard swellings along the urethra, as soon as their 
existence is ascertained. 

Another, and much more rare consequence of an opening of the urethra into 
the sheath, is the gradual formation of one or more fistulous tracks along the penis, 
terminating behind the'corona glandis, and causing a good deal of thickening and 
induration of the tissues alons^heir course. 

Other pathological and physiological relations will doubtless be deduced from 
this anatomical structure, when attention shall be more extensively directed to it. 



1849.] 



Domestic Summary. 



251 



The accompanying drawing, representing the dissection of the sheath of the 
penis, was made by my pupil, Mr. Moreau Morris. 




A dissection of the sheath of the penis, showing, 

A. The corpus cavernosum, enucleated from the sheath. 

B. The sheath, split up through the suspensory ligament, of which it is a continuation. 

C. The relations of the sheath to the corpus spongiosum urethrae, one layer of which 
passes above, the other below it. 

D. Its relations to the glans penis, to which the sheath adheres inseparably by its outer 
surface, while by its inner surface it caps the corpus cavernosum. 

E. The dorsal arteries, veins and nerves, raised with the sheath. 

Rem arks on some of the Diseases which prevailed in the 2d Regt. Mississippi Rifles, for 
the first six months of its service. By Thos. N. Love, M. D., Surgeon to the Regiment. 
{New Orleans Med. and Surg. Journ., July, 1848.) — This interesting paper fur- 
nishes important materials which ought not to be overlooked by the historian who 
shall desire to present a full and impartial narrative of the war with Mexico. To 
arrive at a just estimate of conquests and military glory, the cost ought to be known. 
The following extract from Dr. Love's paper will, we are sure, be read with interest. 

c; The ten companies of volunteers called for by the President in the latter part 
of the year 1846, to serve during the war with Mexico, met at Vicksburg, between 
the 2d and 6th of January 1847. During the march of the respective companies 
from their residences to the place of rendezvous the weather was most deli-hiiul 
— equal to Indian summer. Most of them left home without having provided 
themselves with sufficient clothing, intending to appropriate in this way the money 



252 



American Intelligence. 



[Jan. 



which Government allowed them for this purpose. But few of them were pro- 
vided with woollen clothes and hardly one in ten with flannel. The Governor of 
the State had rented warehouses which were fitted up and appropriated as bar- 
racks for the companies as fa<t as they assembled. These were very uncomfort- 
able for men lately accustomed to feather beds and warm buildings, but these 
were perhaps the best quarters that could have been procured. The troops were, 
however, destined to enjoy these quarters but two or three days. The officers 
appointed for the purpose of organizing the regiment selected an encampment 
two and a half miles above Vicksburg, which, in honour of a gallant officer, they 
named 'Camp McClung.' The men were rapidly mustered into service: not 
having been subjected to a close inspection, the result was that many weak, infirm, 
and broken in constitution had entered the army. Indeed many had volunteered 
for the purpose of restoring their health. As fast as they were mustered they 
marched to the camp, which proved to be a very injudicious selection, situated 
upon a low bank of the river, exposed to a wide sweep of the north and west 
winds. Before the men had fairly pitched their tents or became rested from the 
fatigues of the march, the weather became very inclement. The whole encamp- 
ment was covered with mud and water. The blankets and clothing of the men 
were saturated with water. The young soldiers couch was made upon the damp 
and chilling earth, rife with disease and death. Add to these misfortunes, they 
were suddenly placed upon the diet of camp life. On the 10th of January one of 
the most remarkable changes in the weather occurred I remember ever to have 
witnessed. The previous night the windows of the very heavens seemed to have 
been opened, and torrents of rain came like a flood over the encampment. Early 
in the morning the cold north wind came sweeping down from the broad bosom of 
the Mississippi, bringing with it a storm of sleet and hail. The situation of the troops 
now became truly distressing. The inclemency of the weather was such that it 
was impossible to furnish them provisions and wood sufficiently or regularly. 
Some muffled themselves up in their dripping blankets and huddled together in 
their cold and comfortless tents; some hovered over the smoking fires, calmly 
submitting to the pitiless peltings of the storm, and others, with their wet and 
frozen blankets close around them, wandered forth through the streets, friendless, 
homeless, and houseless. Language fails to give an adequate idea of the suffer- 
ings of our men. They felt { as if the very marrow of their bones was congealed.' 

u These causes, which I have briefly enumerated: — fatigue, exposure, insuffi- 
cient food and clothing, were soon followed by the most remarkable and disas- 
trous effects — influenza, rheumatism, pneumonia and a disease more formidable 
than them all — cold phgue. In this condition the regiment embarked on board 
steamboats for New Orleans. Our men were here prostrated by dozens; unpro- 
vided with medicines, or even a shelter, they were compelled to seek that com- 
fort which their friends could best procure for them. The situation of the troops 
became so distressing that they were removed as fast as possible to the Battle 
Ground below New Orleans. All but two companies were transported upon the 
13th and 14th of January. Two companies had taken quarters in Vicksburg and 
were not transported until the 18th. The citizens of Vicksburg no doubt remember 
well the eccentricities of a Captain who marched his company about the streets 
day and night, through mud and water, the result of which was subsequently 
manifested in a greater proportion of mortality among his men than almost any 
other company. 

u During the transportation of the troops to the Battle Ground, their sufferings, if 
possible, were increased. Every day we had more or less rain ; the cold wind 
shifting from every point of the compass. The men were crowded upon steam- 
boats, with their wet tents and damp blankets piled about them, poorly provided 
with shelter and no conveniences for cooking. It was distressing to go among 
them at night and hear the incessant coughing of hundreds, and the lamentations 
of the sick, suffering with cold and calling for the simplest wants. 

" It was during showers of rain and blasts of cold wintry winds that they erected 
their encampment upon the Ratile Ground, and upon an earth saturated with water, 
they made their beds. One hour the sun shone out beautifully, the next the sol- 
diers were seen murfled in their blankets, turning from the cold wind, and the 
next they were found huddling in their tents from the torrents of rain. Not a dry 



1849.] 



Domestic Summary. 



253 



foot of land was to be found in the whole encampment. The heat of the fevered 
patients vapourized the dampness of the blankets, creating in their tents a dense, 
suffocating steam. 

" In this condition medical treatment was unavailing, and not until the seal of 
death had fixed the destiny of many a brave soldier, did our Government officers 
pretend to offer the least assistance, and at last it was only to the dying soldier 
they gave a scanty couch of straw within the walls of a cheerless building, far more 
comfortable, however, than was our former condition. Many of our sick had 
already sought lodgings at their own expense in private hospitals and boarding 
houses. When comfortable quarters were not allowed by officers whose duty it 
was to procure them, our officers very justly granted permission to their men, who 
were sick, to seek for themselves lodgings in the city. The removal of the sick 
to the hospitals was a distressing scene. On one occasion more than fifty were 
taken to Dr. Luzenberg's Hospital. They were first taken, in cabs, to the river, 
then crowded into the cabin of a small towboat, then again into cabs to be 
transported to the railroad and thence into the cars, and before they were safely 
lodged in the hospital it was midnight; many of them apparently suffering with 
severe inflammatory rheumatism, and at every effort to move them was uttered 
an involuntary scream of agony. It would be ungrateful in me not to ackowledge 
in this connection, the kind attentions and unceasing energy with which Dr. Mc 
Cormick, the Medical Purveyor of New Orleans, laboured night and day to 
afford us relief. The private physicians of the city were exceedingly kind in be- 
stowing their services, of whom none is more deserving of our sincerest gratitude 
than Dr. Fenner. 

u The next step was to remove the troops upon the transports, for which we had 
waited impatiently for several days. Here our sick list continued to increase. 
The situation of the troops was but little better than in camp. In the holds of three 
ships were crowded nearly 800 men; their tents, blankets, and clothing still very 
damp, the weather being so inclement that it was impossible to dry them. The 
berths were made of green pine plank which were as cold and hard as marble. 
Upon these our sick men were confined. They were not even allowed straw 
matresses although they were earnestly required and demanded, and could have 
been procured for one dollar a-piece. I have seen the sick soldier in his delirium, 
raging with madness and writhing under the terrors of disease, tear his flesh upon 
the rough sides of his rugged couch. At length all our sick were removed from 
the ships to the hospital, and on the 30th of January we were sailing fast from the 
scene of desolation, with the sanguine hope that we had left behind us the scourge. 
Indeed, we had left behind eighty of our men that were destined never to join us 
again. But our brightest hopes were soon at an end. The dark cloud of disease 
still hovered over us. The holds of the ships offered scenes distressing to the 
most callous heart. The evaporation from the dampness of the blankets and tents 
settled in great drops upon the ceiling. The holds of the ships were soon crowded 
with the sick. The effluvia was intolerable. The attendants were young and 
inexperienced. The sea became rough and the companions of the sick were no 
longer able to give their kind attention. They had nothing to eat which a peevish 
appetite would crave. Here the soldier was deprived of the simple attentions of 
a kind mother and sisters, who come around the couch of a sick man like minis- 
tering angels. Through the long dark night the rolling ship would dash the sick 
man from side to side, bruising his flesh upon the rough corners of his berth. The 
wild screams of the delirious, the lamentations of the sick, and the melancholy 
groans of the dying, kept up one continual scene of confusion. We had a long 
tedious voyage — four weeks we were confined to the loathsome ships, and before 
we had landed at the Brazos, we consigned twenty-eight of our men to the dark 
waves." 

Dr. L. states, at -six months after the regiment had entered the service, it had 
sustained a loss of 167 by death, and 134 by discharges. 

Anthropo-toxicologia. — The New Orleans Med. and Surg. Journ. (July, 1848) con- 
tains some interesting observations by Dr. C. E. Lavender, of Selma. Ala., relative 
to " that form of poison generated in, or secreted from, one healthy person capable of 
producing disease in another human being subject to its influence." 
No. XXXIIL— Jan., 1849. 17 



254 



American Intelligence. 



[Jan. 



"That the human body in a state of disease is capable/ 7 Dr. L. observes, <c of 
sending forth a contagious or infectious poison, is familiar to every one. That 
the natural and normal secretions of certain animals are poisonous and will, when 
received in the human system, produce disease and death, is equally true. But 
that the secretions or exhalations from some human beings in health, are so viru- 
lent and noxious as to cause disease in other healthy persons, is a position that 
will not readily he conceded, and must therefore be examined." 

To throw light upon this subject, Dr. L. relates three cases. The subjects of the 
two first were the two wives of the same man who were at the period of marriage 
in good health, but soon afterwards sickened and died. The subject of the third 
was the wife of a second man, and the phenomena presented were the same. 

" The toxicological symptoms in these cases are the constant and gradual ema- 
ciation and waste of vitality, without any apparent fixed disease; the optic illu- 
sions, especially the fact of light appearing scarlet, and white red; the coincidence 
of the symptoms under similar circumstances; and the fatal termination. 

u The anthropological facts are these: P. K., the husband of the two women 
whose cases are detailed (and the remarks will equally apply to D. W., the hus- 
band of the third), is a man whose cutaneous secretions, especially under ex- 
citement, are known to be exceedingly offensive and disgusting. ' Essentially 
an unclean animal, all the civet of the apothecary, mixed with the perfumes of 
Araby the blessed, cannot sweeten him. ; Is it not possible, nay, is it not proba- 
ble, that the inhalation of these gaseous secretions or the absorption of others, 
from this living laboratory of malaria, may have produced deleterious impressions 
on those constantly subjected to their influence, causing a specific and fatal train 
of morbid associations'? 

" These two women were in the prime of life, in robust health, of good constitu- 
tion, and of active, healthful habits. So soon as they came in contact with this 
man, they began to exhibit the effects of morbific causes. They both became 
leucophlegmatic, and continued constantly and steadily to decline. The same 
optic illusions, dimness of vision and perversion of colours, marked the progress 
of both cases to a fatal termination. 

" The matter of contagion is no more cognizable to our senses than malaria. In- 
fectious disease is, however, usually attended by a certain very sensible faetor. 
Persons whose bodies, in a state of health, are capable of elaborating infection, 
as far as my observation extends, are distinguished by the strong and peculiarly 
offensive character of their pulmonary and cutaneous exhalations. Although this 
may not always be the case, yet so singly is it true in the cases before us, that I 
have heard sensible men say that, in their opinion, it would cause disease in any 
person who would room with them. I therefore set this morbific agent down in 
the catalogue of animal poisons, as human infection sui generis. What its nature, 
its essence — from what part of the body derived, and upon what tissue it first 
makes its attack, are, at present, matters of conjecture. Whether all persons are 
obnoxious to this poison, or whether there is a peculiarity in some, rendering 
them more susceptible of its action than others, time and observation must decide. 
In the cases above noted the noxious cause evinced its power by depressing the 
vital energies, impoverishing the vital fluid, and deranging the sensorium. There 
are. doubtless, instances in which the infection, not being sufficiently concentrated 
or virulent to cause fatal consequences, makes known its existence in the continued 
bad health and low spirits of its victim. And this, it may be, is the secret why 
so many hysterical cases are so difficult to be controlled, and why in such cases 
the experience of our profession finds it profitable to prescribe temporary absque 
marito" 

Bite of the Cerastes Nasicornis, the Horned Viper of Western Africa. (Proceedings 
of the Academy Nat. Sciences of Philadelphia, April 11, 1848.) — Dr. T. S. Savage, 
in a letter to Dr. Hallowell, has furnished some interesting information relative to 
the bite of the horned viper of Western Africa, and its treatment. He states 
that the natives dread this serpent more than any other — its poison is very intense, 
generally proving immediately fatal, though sometimes the animal bitten survives 
for hours. 

" The native treatment for the bite of this, and all other serpents, is," he says, 



1849.] 



Domestic Summary. 



255 



"to suck out the poison; make a free incision over the wound, and apply the juice 
of an unknown plant, sometimes a strong decoction of the same. Recovery is 
sometimes said to occur, but very rarely, however. A direct, deep flesh wound 
is supposed always to prove fatal. 

"The symptoms are, severe pain in the parts — rigors more or less palpable — 
sensation of heat — vomiting — profuse perspiration and purging. If not much re- 
duction of vital energy attend, there is a possibility of recovery; but if, on the 
contrary, an early sickness comes on, there can be no hope — death soon follows. 

i: A case occurred at one of our mission stations, supposed to be from the bite 
of this viper, though it is not certain. A young man had been out in search of 
Palm-nuts (fruit of the Elais guiniensis.) As he was returning, he heard the 
warning sound, but knowing the habits of the reptile, and supposing it to be on 
one side, he proceeded without precaution, and was bitten in the calf of his leg. 
He represented himself as being immediately disabled. He halloed till some one 
came to his relief, and was carried on the mission premises, which were at hand. 
It is supposed that a half hour, perhaps an hour, had passed. The leg, when first 
seen, was greatly swollen, nearly to the size of his thigh; the skin was tense and 
hot, with great pain in the surrounding parts. A free incision was made, and the 
blood pressed out. Stimulants and narcotics were freely given, and recovery suc- 
ceeded. 

"The intensity of the poison has been manifested several times in the case of 
dogs. One case of this kind came under my immediate notice. Some of the 
mission scholars had permission to spend an afternoon in hunting. They pro- 
cured for this purpose a valuable dog from a neighbouring colonist. They had 
not left the road for the thicket long, before they heard a piercing cry of distress 
from the dog. They ran immediately to the spot, where they saw this viper, and 
the dog lying on his back, as if in convulsions. They shot the serpent, and carried 
them both to the road, by which time the dog was dead. From a minute examin- 
ation into the circumstances of the case, I was convinced that not more than 
fifteen minutes could have transpired from the bite, to the death of the dog. 

" It may not be irrelevant here to remark, that several cases of bites and stings 
of venomous reptiles and insects, have come under my notice at Cape Palmas, 
which I have treated on the principles above stated. I have heard of deaths from 
these causes, but none have fallen -within my observation. One case, that of a 
colonist, nearly proved fatal, but I supposed it was from the time the poison had to 
act in the system before he came under treatment. He was a sawyer and was in 
the act of preparing a log for the saw, when he was bitten by a snake which he 
observed retreating. Being intent upon his work at the time, he did not get a 
good view of it, but said it presented a green aspect, probably another species. 
He had but one companion, who carried him on his back for two or three hours, 
when he reached my premises. The wound was in the foot; this was greatly 
swollen, as was also the leg as high as the knee. He seemed to be greatly pros- 
trated and in great pain; vomited several times a light-coloured watery fluid. I 
immediately administered, in large doses, strong rum and sulphate of morphia, 
and made a free incision over the wound. So reduced was the vitality of the 
parts that scarcely any blood flowed at first, but a passive hemorrhage came on 
subsequently, to stop which the blood vessels had to be taken up and tied. The 
whole limb up to the groin, became enormously swollen ; a bad sore followed 
from the incision, and the cuticle of the leg, to a great extent, came off. He re- 
covered at the end of three weeks." 

Case of Traumatic Tetanus successf ully treated. By S. C. Thornton, M. D. (New 
Jersey Med. Rep., Oct. 1848.) — The subject of this case was a robust man 24 years 
of age, in whom the disease was induced by an injury on the foot caused by 
wearing a tight boot. Dr. T. immediately bled him to the extent of twenty ounces, 
and directed hyd. chlorid. mitis gr. x, every two hours, and morph. sulph. gr. 
every three hours, to be continued till my next visit. In the evening Dr. T. saw 
him again, and directed the spine rubbed with pure potash, and to be covered with 
a blister extending from the nape of the neck to the os-coccyx, and to continue the 
calomel and morphia. The agonies of the patient were now extreme, severe 
spasms occurring every twelve or fifteen minutes. To allay these, chloroform and 
sulphuric ether were administered, and directed to be given alternately every hour 



256 



American Intelligence. 



[Jan. 



during the night, in limited quantities, if circumstances should require it. The 
moment the patient came under the influence of the ether, he cried out M I am 
easy now." The paroxysms were not only moderated, but the intervals between 
them were much longer, so that the poor patient already experienced some relief. 
Nearly an hour would sometimes elapse between the paroxysms. He was ill for 
two weeks, during which time he would occasionally suffer from his tetanic symp- 
toms, but good nursing and a steady perseverance in the remedies finally relieved 
him. The calomel was continued for the first four days; after that, reliance was 
principally placed upon the sudorific effects of the morphia, and the anaesthetic 
agents which have been named. He took four hundred and ten grains of calomel, 
(by which he was freely purged and salivated,) twenty-five grains of morphia, 
consumed twenty-eight ounces of sulphuric ether, and eight ounces of chloroform. 

Ununited Fracture of the Femur of one year's standing, successfully treated by Resec- 
tion, Denudation, and Retaining the ends of Bone by means of Wire. By Daniel 
Brainard, M. D., Professor of Surgery in Rush Medical College. {The North- 
Western Med. and Surg. Journal, Aug. and Sept. 1848.) — The subject of this case 
was a man 34 years of age, who, on the 14th of March, 1847, had his leg frac- 
tured, and the knee, leg and ankle of the same side severely bruised by a tree 
falling on him. There was much bruise at the point of fracture, but the skin was 
not broken. The limb was laid upon a double inclined plain, the leg enveloped 
in a roller, and a piece of flannel pinned about the thigh. Extension was made 
by means of li half a brick" suspended from a cord attached to the foot, and pass- 
ing over the foot of the bed; and counter extension by means of a " flat-iron" sus- 
pended from a cord attached to the pelvis and passing over the head of the bed. 
At the end of five and a half weeks, the weight attached to the foot was increased 
to about sixteen pounds, and the limb was placed in a different apparatus. Du- 
ring the whole of the treatment the roller upon the leg was removed every three 
or four days, and the member at such times subjected to considerable movement. 
At the end of eleven weeks, the apparatus was taken off, and the patient removed 
about a mile, and directed to rise and walk on crutches. This, however, he was 
unable to do. After some time the surgeon examined it and finding it ununited, 
moved the fragments Ireely, and re-applied the apparatus for seven weeks. 

During the whole of this time the point of fracture remained very tender; and 
during the night or when it was moved, there was spasmodic action of the mus- 
cles, which drew forward the upper fragment, " so that it seemed as if it would 
come through the skin," and shortened the member very much. 

When he applied to Prof. Brainard, about the middle of February, 1848, on 
examination, the fracture was found to be situated seven inches above the knee, 
very oblique, the superior fragment placed in front, the ends overlapping, when 
no extension was made, not less than four inches, and the fragments so movable 
that they seemed to have no connection with each other or with the surrounding- 
parts. The extremity of the upper fragment in particular, when acted on by the 
muscles, and drawn inwards, forwards, or outwards, could be felt as if beneath 
the integuments only, and seemed to move as if in a sac. Both ends could be 
felt rounded; there was no tenderness, and the member could be bent almost to a 
right angle at the point of fracture, without giving pain. The member hung dang- 
ling, entirely useless; the thigh, from the want of use, and the pressure of an 
apparatus which he kept buckled around it, was atrophied and attenuated to a 
remarkable degree, while the foot and leg, from the obstructed circulation, were 
swollen, cedematous, and indurated, so that it but partially regained its natural ap- 
pearance when the pressure was removed, and the patient placed in a horizontal 
position. 

On the 1st of March. 1848, with the assistance of Drs. Herrick and Blaney, Dr. 
Brainard operated in the following manner: — 

"An incision w r as made four and a half inches in length, upon the anterior and 
exterior side of the thigh, and carried down to the fracture. The ends of the bones 
were exposed and found to be covered with a tough fibrous tissue of great firm- 
ness. This was removed by means of the bone nippers from the end of the 
lower fragment; the end of the upper piece being very sharp, and having great 
tendency to project forwards, a chain saw was passed around it, and about an 
inch of it removed. 



1849.] 



Domestic Summary. 



257 



Extension being then made, the two extremities were approximated to each 
other, and a piece of silver wire, (like that used for constricting polypi,) doubled 
and twisted, was slipped over each end so as to encircle the two bones. The 
ends of the wire were then twisted together with sufficient firmness to prevent 
movement without exercising much pressure on the surface of the bones. The 
limb was then placed in an angular splint, the sides of the wound brought toge- 
ther with stitches of interrupted suture and splints applied so as to restrain its 
movements.' The operation lasted perhaps half an hour, was well borne by the 
patient, and no vessel required a ligature. It was evidently, so far as the imme- 
diate depressing effects were concerned, much less severe than amputation of the 
thigh. Using the chain saw, instead of turning out the ends of the bones to saw 
them off, renders the operation less severe. Considerable inflammation followed, 
which was combatted with antiphlogistic treatment. The wound healed by the 
first intention excepting at two points of sufficient extent to allow of the escape of 
matter. On the third day the spasm of the muscles of the thigh, before mentioned 
as having followed the fracture, occurred, being excited by the slightest touch or 
motion. It was so severe as to shorten the limb somewhat, and was attended 
with such violent efforts at displacement as to show conclusively the necessity of 
the wire, or some equally effective restraining means. The suppuration dimi- 
nished, the patient's appetite returned, and he was in every way comfortable. 

The object of the wire — that of holding the ends of the bone firmly in contact 
until adhesions might be formed — having been accomplished, it was desirable to 
remove it. This was done on the 24th of March, as carefully as possible, but 
some inflammation followed, and on the 4th of April, fluctuation was perceived 
on the inside of the thigh, and a puncture was made. Under the use of astringent 
injections, the abscess contracted rapidly, and on the 16th of April there remained 
only a fistulous opening on the outside, and another on the inside, through which 
a few drops of serum could be pressed. At the end of twelve weeks he was 
allowed to move the limb in bed, and in four months he walked on crutches, the 
union being complete. At the present time, August 1st, he moves the member 
with great facility; the muscles, atrophied from long inaction and pressure, are 
being developed by use; and, although considerably shortened, it is far superior 
to any artificial limb. 

Successful Amputation at the Shoulder -joint, for Gunshot Wound — patient under Chlo- 
roform. By Paul F. Eve, M. D., Prof., &c. &c. {South. Med. and Surg. Journ., 
Nov. 1848.) — The subject of this case was a black boy, accidentally wounded by 
the discharge of a gun at the distance of a few feet. The load, which consisted 
of squirrel shot, entered the left arm about an inch below the acromion process of 
the scapula, and the shot, after cutting the os humeri nearly in two, passed in the 
direction of the shoulder-joint and subclavian artery. His pulse, when Dr. E. first 
saw him, forty-eight hours after the accident, was over 100; his fingers of the in- 
jured side he said were benumbed, and he complained of pain in the region of 
the wound. The arteries of the left upper extremity pulsated distinctly; the age 
of the patient was eleven ; his general health good. His bowels had been moved 
with salts, and fifty drops of laudanum had also been given to procure ease and 
sleep. 

Amputation having been decided upon in consultation, it was performed — with 
the assistance of Dr. Dugas who controlled the circulation by pressure on the sub- 
clavian artery, and of Dr. Means who administered the chloroform — in the following 
manner. "The heel of the amputating knife was applied upon the anterior edge 
of the acromion, and by a continuous sweep around the head of the os humeri, 
two flaps, one anteriorly and the other posteriorly, were made, and the operation 
completed by ligating four or five arteries. In carrying the elbow forward, to throw 
the head of the bone backwards so that the knife might the more easily pass 
through the joint, the humerus was fraciured, so near was its complete division by 
the shot, which must have entered en masse. The time consumed in the amputa- 
tion, was thus increased by this fracture, but the longest estimate of those present 
was twenty-two seconds. 

"The insensibility," Dr. E. states, "produced by the chloroform was extremely 
satisfactory; the operation having been performed and the dressing applied without 



258 



American Intelligence. 



[Jan. 



the knowledge of the patient. He was sitting up on the fourth, and left the sur- 
gical infirmary on the seventh day. 

u With the exception of some delay from the shortness of the flaps, owing to 
the destruction of the deltoid muscle by the wound, the discharge of a few shot 
from it, and some fever created or rather aggravated by worms, he had a good 
recovery, and is now a hearty, well boy." 

Aneurismal Tumour of a branch of the Epigastrium bursting into the Scrotal Sac. 
By M. Z. Kreider, M. D., of Lancaster, Ohio. — George Hanstein, aged 48 years, 
stonecutter, presented himself for relief, June 27th, 1841. The following is the 
history of this case. About twelve years ago, while engaged in turning a large 
granite block, one corner of the stone came in violent contact with the os pubis 
on the left side of the root of the penis. A slinging pain was felt for some time 
after the accident. A few days afterwards, a small pulsating tumour (about the 
size of a hazelnut) was found to occupy the seat of the injury. This tumour very 
slowly enlarged ever since that time, until it attained the size of a large hen-egg. 
It has at no time been a source of much inconvenience. A week since the man 
went to bed as usual — about midnight he awakened suddenly, feeling a stinging 
pain about the place of the tumour, and putting down his hand to the part, was 
surprised to find that the tumour had disappeared. He soon, however, discovered 
that the scrotum was much enlarged, and that this enlargement was rapidly aug- 
menting. The following are the dimensions of the scrotum at this time — length 
two feet; circumference near apex, seventeen inches; at middle twenty-two 
inches. Upon making an incision into the scrotum upon the left side, a large 
quantity of partially coagulated arterial blood escaped. Finding that hemorrhage 
still continued, I dilated the wound upwards and found the bleeding vessel to be 
a branch of the epigastric — and was the vessel which had been originally injured, 
forming an aneurism, whose walls giving way, had suffered the blood to escape 
and find its way into the scrotal sac. The vessel was secured by ligature — the 
coagula entirely removed from the scrotum, the wound closed by interrupted 
sutures and adhesive strips — some slight suppuration followed — but in a few days 
the parts healed and the man speedily and perfectly recovered. — Ohio Med. and 
Surg. Journ., Nov. 1848. 

Fibrous Tumour of the Uterus — Gastrotomy. By Dr. J. Deane. {Boston Med. 
and Surg. Journ., Oct. 11th, 1848 ) — The subject of this case was a healthy woman, 
43 years of age, the mother of several children, who, early in the year of 1847, 
discovered a small tumour in the left iliac region, which continued to increase. 
When the patient was seen by Dr. Deane. the tumour was central and occupied 
the hypogastric and iliac regions, but inclined a little to the left side. It reached 
from the pubis to the ensiform appendage nearly, and admitted of pretty free 
lateral movements. It was globular, symmetrical, smooth and solid. Explored 
by the natural passages it was found to rest upon the pubis in front and the sacrum 
behind. In the recumbent posture it could be raised upon the finger and a free 
impulse communicated to it, but in the erect position it was immovable. Its 
length might be 8 or 9 inches and breadth 5 or 6, and from repeated examinations 
by Dr. Duncan her family physician and Dr. Deane, the tumour was judged to 
spring from the left ovarium, although they were by no means sure it was not ute- 
rine. There appeared to be no deviation in respect to the place and condition of 
the os uteri, nor were the periodical functions of the uterus interrupted by the 
proximity of the tumour. It was never attended with pain or tenderness; it ap- 
peared suddenly and increased rapidly, but beyond this the local or consitutional 
disturbances were very slight indeed, and we did not hesitate to regard this mor- 
bid growth to be non-malignant as yet. The patient being solicitous to take the 
perilous alternative of an operation, after its dangers were faithfully set forth, the 
6th of June was determined on for that purpose. 

As a preliminary measure the patient was desired to abstain from solid nutri- 
ment and her bowels were emptied by a laxative. The operation was com- 
menced by an incision upon the left side of the umbilicus and carried down to 
the pubis, dividing the integuments and aponeurotic tissues to the peritoneum, 
which was carefully opened to a like extent, when the summit of the tumour was 
conspicuous. It was round, polished, solid, and traversed with innumerable ves- 



1849.] 



Domestic Summary. 



259 



sels that communicated a bright colour to its investing membrane. The primary- 
trunks of these vessels were large. In passing the hands into the pelvic cavity to 
raise the tumour, the intestines escaped with a gush; by this manasuvre it was 
ascertained that no adhesion existed, and that the tumour was without a pedicle! 
In attempting to raise the mass, the movement was suddenly arrested by the 
stretch of the broad uterine ligament, but the uterus was nevertheless fairly dislo- 
cated and brought into view, when the true character and relations of the tumour 
were reveale'd. It was a solid, fibrous tumour of the uterus. 

u The difficulties and dangers of the enterprise," says Dr. D., " were now fully 
apparent. The tumour embraced the entire left half of the uterus, which was 
enlarged and flattened, and appeared to be imbedded in the tumour rather than 
to give origin to it. The origin was continued to the left division of the broad 
ligament, and thereby the position and movements of the tumour were firmly 
fixed. To prosecute the operation, the necessity of removing the uterus and its 
appendages was inevitable; for the possibility of separating the tumour from the 
uterus appeared to be impossible. The tumour received its nutrient vessels from 
the uterus, and the difficulties of controlling the hemorrhage that must result from 
division, seemed too appalling to be encountered. A brief conference was there- 
fore held, when it was the unanimous expression that the further prosecution of 
the operation was impracticable; first, because of the danger of hemorrhage — 
and second, from collapse or from consecutive inflammation, and we were there- 
fore reduced to the miserable necessity of retracing our steps, and averting the 
consequences of the mischief we had already done. 

" The tumour and intestines were therefore returned to their respeciive cavities, 
but not without difficulty, and the wound closed and firmly secured by the inter- 
rupted suture, long adhesive dressings, compresses, and over all a firm binder. 
During this distressing period our patient was unconscious of our doings, chloro- 
form having been previously administered by Dr. Seymour. But this agent 
exerted a pernicious result. Its first inspirations caused paleness and apparent 
distress, manifested by low moanings, which continued until the patient was put 
in bed. But no vomitings or nausea occurred, nor as yet much embarrassment 
of respiration. Right ovary was in a normal state, but left was not seen. The 
tumour was an ellipse, and its attachment to the uterus corresponded to its inferior 
focus. Pulse at commencement, 80; it fell to 72. Temperature 78°. No bleed- 
ing of note occurred. 

" The propriety of abandoning the operation was fully justified by subsequent 
events, for the constitutional disturbances that ensued were severe and threaten- 
ing. These were due to two distinct causes, the inspiration of chloroform and 
structural injury. For three hours after our patient was placed in bed, her suffer- 
ings were intense. Her countenance was pallid, respiration laborious, mind op- 
pressed, and she constantly uttered plaintive moanings. Yet the pulse did not 
indicate approaching collapse. It had gone up to 90. She finally fell into sleep, 
and her breathing then becam'e suspended by intervals of alarming duration. 
For thirty-six hours it was never above four times per minute, oftener but twice, 
frequently but once, and sometimes the pause was a minute and a quarter. She 
was for the most part lethargic, and her muscular system was convulsed with in- 
cessant twitchings. Occasionally she might be roused from stupor, but instantly 
relapsed into insensibility. The extremities were cold. To anticipate supervening 
inflammation, and especially to avert the issue between the inversed order of 
respiration and circulation, eighteen ounces of blood were drawn, but no sensible 
effect was produced upon the respiration. At the end of twelve hours the spasms 
and insensibility had increased; pulse 100, breathing stertorous, fingers livid and 
abdomen tympanitic. During the succeeding twenty-four hours our apprehensions 
were truly painful, the pulse still increasing and breathing diminishing in fre- 
quency. But at the termination of this period, the respirations rose to twelve in 
the minute, and the intellect began to be relieved of its oppression, and hence- 
forth the respiration became unembarrassed. 

" But the case was yet encompassed with perils, for severe inflammatory action 
was now established. From 90, the pulse rapidly increased to 140, and even 
more. The abdomen was tender and full, and would have bursted but for vigilant 
precautions. The tongue was loaded. The severity of the symptoms demanded 
active treatment, which was of course depletory. But, without narrating particu- 



260 



American Intelligence. 



[Jan. 



lars ; it will be sufficient to say that on the eighth day there were evident signs of 
amendment, and we dressed the wound for the first time. It had closed, in spite 
of the distension, except two small spaces at the lower extremity of the incision, 
from which issued a small quantity of dissolved coagulum. Nothing further par- 
ticularly occurred to interrupt recovery; in a fortnight, our patient sat up a little, 
and, finally, although disappointed in our, expectations, we were nevertheless un- 
speakably gratified that the conclusion was no worse." 

Case of Labour where Delivery was accomplished through the Perinceum. By S. C. 
Ellis, M. D. (New York Journ. of Med., Nov. 1848.)— The subject of this was 
thirty years of age, in labour with her first child. When Dr. E. arrived the child's 
head had commenced passing the superior strait of the pelvis, and in an hour or 
little more it was pressing on the perinseum, which soon became very tense and 
thin. The expulsive efforts of the uterus seemed to be directed towards the 
anus, and there was really but little or no distention of the os externum vagina?. 

Fearing laceration, Dr. E. supported the part with his hand, and used all the 
force that was prudent to induce the head to its proper exit, but it would not be 
governed by the considerable power applied, and he felt the perinaeum gradually 
giving way under the palm of his hand like a piece of wet paper. He continued, 
however, to press to the vulva in a desire to save the sphincter ani muscle. All 
was of no avail, so far as natural delivery was concerned : for another pain drove 
the child's head through the perinseum, the whole body following instanter. Being- 
anxious to see the exact nature of the wound, for the purpose of doing what might 
be necessary, Dr. E. immediately introduced his hand through the opening and 
extracted the placenta, which was slightly adherent. 

On inspection he found that the laceration began about an inch from the anus: 
first transverse and running from that on each side of the vulva, making a ragged 
irregular wound, at least one-half of the vulva, including the entire fourchette, 
was hanging loose, and so completely detached that in the examination it was 
turned up and lay over the pubes. 

Notwithstanding all this, Dr. E. says he never attended an easier or more quiet 
labour, and a person in the adjoining room would have scarcely conjectured that 
another being was making its appearance on the scene of life. The lady com- 
plained not, neither had she any idea of the strange manner her fine large child 
had made his debut. 

To conclude, Dr. E. placed the parts in position, put a light compress over the 
wound, after seeing the lochia discharge through the os externum, and in five 
weeks she was up and about, not experiencing, as she has at various times in- 
formed me, the least inconvenience from her rather singular labour. 

Had there been a hymen, Dr. E. thinks it would not have been destroyed. 

Cases and Remarks upon the use of Chloroform in Natural Labour. By Edwin B. 
Stimson, M. D., Resident Physician of New Yorfc Lying-in Asylum. (New York 
Journ. of Med.. Sept. 1848.) — In this paper the author briefly relates ten cases of 
natural labour in which he administered chloroform. In his remarks on these 
cases Dr. Stimson says : — 

" It may be observed of the foregoing cases, — 1st. that the frequency of the 
pulse was diminished during perfect apathy; it was small, thready, and if the inha- 
lation was continued a few moments longer, became almost imperceptible. 2d. 
The respiration grew hurried, short, and interrupted; varying, however, with the 
degree of anaesthesia produced. If the vapour caused sleep only when attendant 
circumstances were favourable to repose, the breathing was in nowise different 
from that of natural slumber. But a marked alteration in the function of respira- 
tion attended the state of profound insensibility. 3d. The muscular system was 
relaxed proportionately to the quantity of the vapour inhaled. Without being sen- 
sible to pain, the patient sometimes flexed and extended the limbs, or aided an 
expulsive effort with the action of the abdominal muscles. If at this period she 
received a few more inhalations in quick succession, her limbs lost all muscular 
resistance, and the body lay motionless. 4th. If the administration was carried so 
far that the pulse fell in frequency, the respiration short and hurried, the muscular 
system lax, and unconsciousness complete, uterine contractions were temporarily 
suspended. The period of their absence was from fifteen to thirty minutes. 



1849.] 



Domestic Summary. 



261 



When they reappeared — as they would do notwithstanding the most profound so- 
por — they were wanting in their original force. Yet, no doubt, their efforts pro- 
moted delivery equally with former throes, as with a diminution of force there 
occurred less resistance from the soft structures of the pelvis. However, such an 
overpowering impression was seldom necessary for procuring the desirable effects 
of chloroform, — a few cases of its exhibition in natural labour teaching that the 
object in view should be rather to tranquilize an excessive susceptibility to pain- 
ful impressions, than utterly to set aside the power of perception. Especially 
does this instruction regard the interval between the commencement of apathy 
and the moment the head is about to glide over the perinaeum. 5th. In no case 
was there an unusual loss of blood ; indeed, I believe I never witnessed, succes- 
sively, the same number of deliveries with so trifling hemorrhage. 6th. In every 
instance did the uterus expel the placenta within twenty minutes after the birth 
of the child. 7th. The fcetal heart beat whilst in utero the same after as before 
the administration of the vapour. The children born were vigorous. 

" The chloroform has always been inhaled from a handkerchief. This mode is 
objectionable on two grounds: first, it is wasteful; and secondly, the vapour that 
escapes sometimes inconveniently affects the attendants. But the facility it offers 
for introducing the agent under the various circumstances and positions of the pa- 
tient more than counterbalances the saving an apparatus would ensure. 

" For a calm and clear restoration of the mental faculties, it was found very 
important after withdrawing the vapour, to allow the patient to sleep undisturbed 
by the least noise or motion. So desirable was it deemed that the patient should 
sleep until the odour of chloroform was no longer perceptible in the breath, that 
in one or two instances I kept up the influence of the vapour till the placenta had 
been expelled, the soiled clothes removed, and the bandage adjusted, leaving no 
cause for disquietude. If the patient be awakened before she is capable of recog- 
nizing her companions, and clearly understanding her new relations, she is likely 
to remain much longer confused than if she had been left unmolested. 

"On the whole, does the experience afforded by the foregoing cases allow us 
to recommend chloroform in natural labour? It certainly does not prohibit the 
article. It rather refers the question of its administration to the patient's disposi- 
tion, so long as our experience does not furnish evidence of an injurious effect. 
If she chooses to be relieved from pain by a remedy which has the power to do 
so as its only claim on her consideration, she may have the article administered 
during the protrusion of the head from the pelvis; and our previous knowledge of 
chloroform, under similar circumstances, will warrant its exhibition. 

"This anaesthetic agent will probably be found more useful in preternatural 
than in natural labours, if we may estimate its suitableness in certain irregular 
conditions by its operation in a regular delivery. Thus it may be employed to 
suspend uterine contraction when the occasion demands version; it may be used 
in cases of irregular contraction of the uterus retaining the placenta, and for arrest- 
ing the recurrence of parturient convulsions. There are accidents, too, which are 
avoided by the use of the vapour; hemorrhage is not as likely to occur with as 
without it, from its property of reducing vascular activity. Rupture of the uterus 
will not take place sooner from its influence ; and from rendering the nervous 
system less mobile, convulsions may be averted." 

Statement of fifteen cases of Midwifery in which Chloroform was administered. By 
Geo. N. Burwell, M. D., (Buffalo Med. Journ., Nov. 1848.)— The author has ad- 
ministered chloroform in fifteen cases of midwifery. The time he has kept his 
patient, more or less continuously, under its influence has varied in the different 
cases from five minutes to one and a half hours. The cases he divides into two 
classes, according to the degree of anaesthesia produced: 1st, those in which it 
was total or nearly so; 2d, those in which a perfect knowledge of everything 
going on was retained, or at least, only momentarily lost. Eight of the cases 
may be included under the first division. We have not space for the details of 
these cases, but must content ourselves with the general remarks that there was 
" a close resemblance in the effects of chloroform upon the system in the first, 
second and fifth cases. There were in these complete anaesthesia, unaccompanied 
with any mental aberration, and nearly entire abrogation of the contractile power 
No. XXXIIL— Jan., 1849. 18 



262 



American Intelligence. 



[Jan. 



of the voluntary muscles. The third closely resembles them, except in the slight 
delirium which accompanied it. The fourth case presents the anomaly of the 
tolerable free use of chloroform failing to produce any very sensible effect over 
the system for better or for worse. The second trial with it succeeded better, by 
lessening the natural expressions of pain, without stopping them, while it destroyed 
all recollection of any pain. The by-standers feel as though the patient were in 
pain, and duly sympathize with her, while she herself feels none. 

"The sixth case is rather anomalous. I can easily fancy that it would be far 
more difficult for those who were by, to believe that she was insensible to all that 
was said and done by herself, as well as by others, than it would be for those to 
whom the case is related. The seventh case shows the curious fact, noticed also 
by others, of pleasant sights, dreams, or emotions occupying the mind of the pa- 
tient while under the influence of this medicine. In the eighth case, the labour 
was unequivocally hastened, I believe, by the inhalation of the chloroform. In the 
condition of the mind it shows some resemblance to the sixth case." 

The second class comprises seven cases. The results afforded by these fully 
demonstrate the proposition, Dr. Burwell considers, of the possibility of exhibit- 
ing chloroform to a point short of causing unconsciousness, or in anywise inter- 
fering with the full use of all her faculties, or the full play of the voluntary mus- 
cles ; and yet so benumbing the pain as to make it quite easy to be borne. I 
would add that we can anticipate this result, not only in occasional cases^ but I 
believe, also, in the large majority of cases. 

" I would be clearly understood, that in all these cases of the second division, 
there were expressions of pain or uneasiness with each contraction of the womb ; 
some more and some less; the voluntary muscles were, in all, excited into full 
action, as is usual when chloroform has not been exhibited. 1 depend upon two 
facts to determine the relief they received ; 1st, the contrast apparent to all be- 
tween their suffering before breathing chloroform, and that while under its influ- 
ence; 2d, their own declarations of decided relief from its use; and their positive 
assertions that if it be their destiny to have more children, they would be sure to 
have it again. 

" The fifteenth case was the least satisfactory, in this respect, of any of the 
second class: being the only one which did not call for it after having once 
breathed it, if we happened to be a little dilatory in giving it to them on the re- 
currence of a pain, or allowed the sponge to get emptied of it." 

Case of Puerperal Convulsions treated by Chloroform. By James P. White, M. D. — 
July 18th, 1848. Was requested by Dr. Devening to see Mrs. Brady, then in labour, 
and suffering from a violent attack of puerperal convulsions. 1 found an Irish 
woman, of full habit, in her third pregnancy, the two previous labours having 
been favourable. Dr. D. had been with her but a short time; the convulsive 
paroxysms succeeding each other with great rapidity; the face flushed and pulse 
full. He had bled her twenty or twenty-four ounces with partial relief. As the 
pulse continued full, and the muscular efforts during the fits were violent, I deemed 
it prudent to repeat the bleeding, which was done to about the previous amount. 
On examination per vaginam, the breach was found occupying the superior strait, 
the soft parts dilatable and the pelvis roomy. As the convulsions continued with 
but slight diminution, and the parts were favourable, though the pains were slight, 
it was deemed prudent to proceed without delay to deliver the child. To secure 
the tonic contraction of the uterus, and guard against hemorrhage, two drachms 
of the wine of ergot were given. It occurred to me that chloroform might assist 
in controlling the woman, and lessening the agitation while making the attempt 
to bring down the child. Dr. D. accordingly applied some of Chilton's prepara- 
tion to the nostrils, whilst I introduced my fingers into the vagina, and hooked 
them into the groin of the foetus. 

The muscular agitation, which before could not be controlled, now subsided, 
and delivery was effected without difficulty ; the uterine contraction continuing to 
be moderate. After applying such restoratives as were requisite to recover the 
child from a state of partial asphyxia, I applied a ligature to the cord, and laid it 
upon the bed. By placing the hand upon the abdomen, it was found to be still dis- 
tended. Upon the re-introduction of the finger into the vagina, it came in con- 
tact with the arm of a second child ; which I proceeded to turn and deliver, the 



1849.] 



Domestic Summary. 



263 



patient inhaling the chloroform, and remaining quiet, with tolerably firm contrac- 
tion of the uterus upon the hand during the operation. The double placenta and 
membranes were very soon pushed down into the vagina by the tonic contraction 
of the uterus, and were, removed by Dr. Devening. Very little hemorrhage fol- 
lowed, and the proper bandage being applied, the patient was carefully laid back 
upon the bed. During the entire period succeeding the application of the anaes- 
thetic agent,, the woman was unconscious and calm, but at no time did we carry it 
so far as to produce stertorous breathing. 

2 1st. The patient comfortable, and consciousness entirely restored. She has no 
recollection of anything which occurred during her labour after being seized with 
convulsions. The children are of good size, and doing well. 

25th. From Dr. Devening I learn that the woman has so far recovered as to re- 
sume her usual domestic duties. — Buffalo Medical Journal, Sept. 1848. 

Malignant Cholera. — We regret to have to record the fact that this disease, in its 
progress, has reached our country. It has appeared at two remote points: first at 
the Quarantine Station at Staten Island, and next at New Orleans. In both places 
the disease commenced among the passengers of ships, ariving at the above 
mentioned ports. The history of its occurrence at Staten Island is said (Annalist, 
Dec. 15, 1848) to be this: 

" The disease first made its appearance on board the American packet ship New 
York, when she was near Cape Sable, on the American coast. The ship had left 
Havre with 345 steerage passengers on board. There was no cholera in that port 
at the time the ship left, and no sickness among the crew until the time mentioned 
above, which was sixteen or seventeen days after leaving Havre. The day the 
disease first appeared on the ship, the barometer had fallen several degrees, and 
the weather become much warmer. When the ship reached this port, she had 
on board eight or ten cases, and several had already died. The sick were re- 
moved to the quarantine hospital, and the rest of the crew to the storage houses 
belonging thereto. 

" What is very singular, all the cases occurring among the passengers, have been 
those from Paris, where no cholera existed when they left; while the German pas- 
sengers, direct from cholera districts, have been entirely exempt." 

Since its first appearance the disease has continued to propagate itself up to the 
present time, — one, two, or three cases occurring daily, but exclusively among 
the inmates of the hospitals, — the inhabitants of the Island, beyond the quarantine 
station, being entirely exempt. It has not there exhibited any epidemic character. 
What is very remarkable, also, is, that one-third of the whole number of patients 
at the Quarantine Hospital have been children under 14 years of age. 

In New Orleans the disease is said to have been introduced by a vessel from 
Bremen, and at the latest dates it was prevailing to an alarming extent, as many 
as 201 deaths having been reported from it in two days, (24th and 25th Dec.) It 
has also manifested itself on board many of the steamboats on the Mississippi 
River, and has in this way extended up, it is asserted, as high as Vicksburg, and 
is daily making further progress. It will be something new in the history of epi- 
demics in this country, supposing the cholera to be such, should it reach the north 
and east in this way, every epidemic of which we have the history having fol- 
lowed an exactly opposite route, commencing at the northeast, and extending to 
the south and west. 

Statistics of the Medical Colleges of the United States for the Session of 1847-48. — It 
will be perceived that the following table is incomplete, but it is as perfect as the 
materials furnished enable us to make it. 



University of Pennsylvania 

Medical College of Harvard University (Boston) 
College of Physic and Surgery (New York) 
Medical Institute of Yale College 
Medical School of Maine (Brunswick) . 
Vermont Medical College (Woodstock) . 
Medical College of Castleton (Vermont) 
Dartmouth Medical College . . . 



No. of 
Students. 

50S 



No. of 
Graduates. 
174 



193 



52 
12 
16 



52 



264 



American Intelligence. 



421 


133 


88 


21 


93 


31 


4S0 


178 


90 


40 


67 




192 


7S 


151 


52 


160 


28 


104 


22 


167 


50 


406 


94 


138 




240 




117 


27 


14C 


31 


SO 


18 


146 


39 



Berkshire Medical Institution 

Medical Department University of City of New York 
Albany Medical College . 
Geneva Medical College . 
Medical Department University of Buffalo 
Jefferson Medical College 
Pennsylvania College Medical Department 
Franklin Medical College 
Philadelphia College of Medicine 
University of Maryland . 
Washington University of Baltimore 
Medical Department of Columbian College 
University of Virginia 
Winchester Medical College 

Medical Department of Hampden Sidney College (Richmond) 
Medical College State of South Carolina 
Medical College of Georgia 
Medical Department University of Louisiana 
Memphis Medical College (Tennessee; 
Medicai Department Transylvania University 
Medical Department University of Louisville 
Medical College of Ohio 
Starling Medical College (Columbus) 

Medical Department Western Reserve College (Cleveland) 
Indiana Medical College (Laporte) 
Medical Department Illinois College 
Rush Medical College (Chicago) . 
Medical Department St. Louis University 
Medical Department University of Missouri (St. Louis) 

Medical Literature. — We learn with pleasure that Dr. Stille's work on Therapeu- 
tics is in a state of forwardness and that the author will labour industriously at it 
until completed. The extensive research, discriminating judgment and practical 
tact of the author are sufficient guarantees that his work will be a valuable one. 

Prof. Meigs' Obstetrics, with numerous wood-cut illustrations, and also his Trea- 
tise on the Diseases of Infants, are in press, and their appearance may be looked 
for shortly. The author's extensive experience cannot fail to furnish much of 
practical value, and these volumes will doubtless be a valuable contribution to our 
science. 

We are also informed that Dr. Griffith's Medical Formulary is nearly ready for 
the press. 

AMERICAN MEDICAL ASSOCIATION. 
By desire of the Committee of Arrangements, the undersigned request all 
Societies and other Institutions, authorized to appoint delegates, to send cor- 
rect lists of those chosen to attend the next annual meeting, to Dr. Henry 
J. Bowditch, Boston, on or before the 1st of April, 1849. 

Editors of Medical Journals are respectfully solicited to circulate the 
above request, a compliance with which will greatly facilitate the organiza- 
tion of the Delegates when assembled. 

ALFRED STILLT5, ) „ , p a %ji a 

HENRY J. BOWDITCH, 5 * ec s °J M ' m ' J1 ' 

0^7= The Association, at its meeting in Baltimore, directed that a copy of the 
Transactions should be sent to such members only, as have paid the annual assess- 
ment for the present year (three dollars). Those members paying to the Treasurer 
five dollars are entitled to three copies. 

Medical Societies which have been represented in the Association will be fur- 
nished copies on the same terms as members (viz., three copies for five dollars) 
on remitting the amount to the Treasurer. 

To other persons the Transactions will be furnished at the rate of two dollars 
per c:>py in paper covers, done up for mail, or two dollars and fifty cents in em- 
bossed cloth, on remitting: the amount direct to Messrs. Lea& Blanchard, Philadel- 
phia. Or orders left with booksellers will be executed by Messrs. Lea & Blan- 
chard. 



THE 

AMERICAN JOURNAL 
THE MEDICAL SCIENCES 

FOE APRIL 1849, 



CONTRIBUTORS TO THIS VOLUME. 

W. L. Atlee, M. D., Prof, of Chemistry in Pennsylvania Medical College, 
George C. Blackman, M. D., of Newburgh, N. Y. 
A. M. Blanton, M. D., of Frankfort , Kentucky.] 
H. Bond, M. D., of Philadelphia. 

Robert Bridges, M. D., Professor of Chemistry in the Philadelphia College of Pharmacy. 
F. W. Clement, M. D., of Delaware. 

D. F. Condie, M.D., of Philadelphia. 

Pliny Earle, M. D., Physician to the Bloomingdale Asylum for the Insane, N. Y. 
' George Fox, M. D., one of the Surgeons to the Pennsylvania Hospital. 
James F. Gayley, M. D., of Philadelphia. 
John H. Griffin, M. D., of Salem, Va. 

S. D. Gross, M. D., Professor of Surgery in the Medical Department of the University of 
Louisville. 

Henry Hartshorne, M. D., of Philadelphia. 

Isaac Hays, M. D., one of the Surgeons to Wills Hospital. 

Samuel Jackson, M. D., Professor of the Institutes of Medicine in University of Penn- 
sylvania. 

Edward Jarvis, M. D., of Dorchester, Mass. 
Joseph Leidy, M. D., of Philadelphia. 
John A. Lockwood, M. D., Surgeon, U. S. N. 

J. Forsyth Meigs, M. D., Lecturer on Diseases of Children. Philadelphia. 
Richard M'Sherry, M. D., P. A. S. U. S. N. 

E. R. Peaslee, M. D., Professor of Anatomy in Dartmouth College. 

Samuel Parkman, M. D., Secretary of the Boston Society for Medical Improvement. 
Isaac G.Porter, M.D., of New London. 
Robert Robson, M. D., of Indiana. 

F. W. Sargent, M. D., one of the Physicians to Girard College. 
Alfred Stille, M. D., Lecturer on Pathology and Practice of Medicine. 
Edward R. Squibb, M.D., Assistant Surgeon, U. S.N. 

John C. Warren, M. D., Emeritus Professor of Surgery in the Medical Department of 
Harvard University. 

J. Mason Warren, M. D., one of the Surgeons"of the Massachusetts General Hospital. 
J. Wister Walke, M. D., of Chesterfield Coal Mines, Va. 
Wilmer Worthington, M. D., of Westchester, Penn. 
J. Young, M. D., of Chester , Penn. 



TO READERS AND CORRESPONDENTS. 



Though we have largely exceeded our limits, it has been necessary to post- 
pone until our next number, several original articles, two Reviews, and a num- 
ber of Bibliographical Notices prepared for the present one. 

"We must request our correspondents who desire their communications to 
appear in the July No., to forward them early, as that No. will be put to press 
on the 1st of May. 

The following works have been received : — 

Medico-Chirurgical Transactions. Published by the Royal Medical and Chi- 
rurgical Society of London. Second series, Vol. XIII. London, 1848. (From 
the Society.) 

On the Influenza, or Epidemic Catarrhal Fever of 1847-8. By Thomas Be- 
vill Peacock, M. D., L.R.C.P., &c. &c. London, John Churchill, 1848. (From 
the Author.) 

The Quarterly Journal of the Chemical Society of London. Edited for the 
Society by Edmund Ronalds, Ph. D. Jan. 1849. (In exchange.) 

Summary of the Transactions of the College of Physicians of Philadelphia, 
Sept. 6, 1848, to Jan. 2, 1849, inclusive. (From the College.) 

Report of a Joint Special Committee of Select and Common Councils, (ap- 
pointed on the 7th Dec. 1848,) to whom was referred certain queries contained 
in a circular letter from the American Medical Association, on the subject of 
Special Hygiene. Published by order of Councils. Philadelphia, 1849. (From 
C. A. Poulson, Esq., Chairman of Committee.) 

Obstetrics: the Science and the Art. By Charles D. Meigs, M.D., Prof, of 
Med. and the Diseases of Women and Children in Jefferson Medical College. 
With 121 illustrations. Philadelphia. Lea & Blanchard, 1849. (From the 
Publishers.) 

On the Cryptogamous origin of Malarious and Epidemic Fevers. By J. K. 
Mitchell, A. M., M. D., Prof, of Pract. Med. in the Jefferson Medical College. 
Philadelphia, Lea & Blanchard, 1849. (From the Author.) 

Manual of Physiology. By William Senhotise Kirkes, M.D., assisted by 
James Paget, Lecturer on General Anatomy and Physiology at St. Bartholo- 
mew's Hospital. With 118 illustrations on wood. Philadelphia, Lea & Blanch- 
ard, 1849. (From the Publishers.) 

An Introduction to Practical Chemistry, including Analysis. By John E, 
Bowman, Demonstrator of Chemistry in King's College, London. Philadelphia, 
Lea & Blanchard, 1849. (From the Publishers.) 

A Practical Treatise on the Domestic Management and most important Dis- 
eases of advanced life. With an Appendix, containing a series of cases illustra- 
tive of a new and successful mode of treating lumbago and other forms of 
chronic rheumatism, sciatica, and other neuralgic affections, and certain forms 
of Paralysis. By Geo. E. Day, M.D., F.R.C.P., &c. Lea & Blanchard, 1849. 
(From the Publishers.) 

Chemical and Pharmaceutical Manipulations. A Manual of the Mechanical 
and Chemico-Mechanical operations of the Laboratory, containing a complete 
description of the most approved apparatus, with instructions as to their appli- 
cation and management, both in manufacturing processes, and in the more 
exact details of analyses and accurate research, for the use of chemists, drug- 
gists, teachers and students. By Campbell Morfit, Practical and Analytic 
Chemist, &c. &c, .assisted by Alexander Muckle, Chemical Assistant in Prof. 
Booth's Laboratory. With 420 illustrations. Philadelphia, Lindsav & Blakis- 
ton, 1849. (From the Publishers.) 

Some account of an Epidemic Cerebro-Spinal Meningitis, which prevailed in 
Montgomery, Ala., in the winter and spring of 1848. Read before the Medical 
Society of Montgomery, Ala. in 1848. By S. Ames, M. D. (From the Author.) 

Notes on the Medical Application of Electricity. By Wm. F. Chaxxixg, 
M.D. Boston, 1849. (From the Author.) 

Memorial of the American Statistical Association for a Sanitary Survey of 



268 



TO READERS AND CORRESPONDENTS. 



the State (Massachusetts). House Document, Nov. 16, 1848. (From Dr. E. 
Jarvis.) 

Seventh Annual Report to the Legislature relative to the Registry, and re- 
turns of Births, Marriages, and Deaths in Massachusetts, for the year ending 
April 30th, 1848. By Wm. B. Calhoun, Secretary of the Commonwealth. 
Boston, 1848. (From E. Jarvis, M.D.) 

Report of the Board of Visitors and of the Superintendent of the Boston Lu- 
natic Asylum, for 1848. ^ Boston, 1849. (From Dr. E. H. Stedman.) 

Report of the consulting Plrysicians of the city of Boston in relation to the 
action of Cochituate Water upon Mineral Substances. Boston, 1848. (From 
E. Jarvis, M.D.) 

General Abstract of the Bills of Mortality for the City of Boston, (for the 
years 1844, 5, 7, 8,) agreeably